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Ph 1 harris hanna_slack

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Pharmacy: Improving Communications with Physicians - Dr. Catherine Hanna, Dr. Patrice Harrice and Dr. P. Tennent Slack

Pharmacy: Improving Communications with Physicians - Dr. Catherine Hanna, Dr. Patrice Harrice and Dr. P. Tennent Slack

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  • 1. Pharmacy  Track:    Improving  Communica5ons   with  Physicians     Patrice  A.  Harris,  MD   Catherine  Hanna,  RPh.  PharmD   P.  Tennent  Slack,  MD  
  • 2. •  Patrice  A.  Harris  has  no  financial  rela;onships   with  proprietary  en;;es  that  produce  health   care  goods  and  services.   •  Catherine  Hanna  has  no  financial  rela;onships   with  proprietary  en;;es  that  produce  health   care  goods  and  services.   •  P.  Tennent  Slack  has  no  financial  rela;onships   with  proprietary  en;;es  that  produce  health   care  goods  and  services.   Disclosures  
  • 3. 1.  Outline  the  strategies  for  collabora;ng  across   professional  lines  for  the  adequate  treatment  of   pa;ents.     2.  Describe  best  prac;ces  for  dispensers  to   communicate  with  prescribers.     3.  Evaluate  the  challenges  for  health  care   professionals  in  communica;ng  about  their   pa;ents  and  offer  solu;ons.   Objec;ves  
  • 4. America’s  Rx  drug  abuse     and  diversion  crisis   Patrice A. Harris, MD National Rx Drug Abuse Summit April 2014
  • 5. Goals  of  presenta;on   •  What  is  the  AMA’s  interest  in  “pain”?   •  Enhancing  educa;on   •  Challenges  facing  health  care  professionals   •  Par;ng  thoughts   5
  • 6. The  AMA  interest  in  “pain”   •  Support  legisla;on  to  combat  prescrip;on   drug  abuse  and  diversion   •  Enhance  educa;on  and  appropriate  efforts  to   ensure  access  to  appropriate  pain   management     •  Increase  access  to  treatment  for  substance   abuse  and  addic;on     6  
  • 7. 7  
  • 8. NO     Pain   NO     Gain   8  
  • 9. 9
  • 10. 10 Drug  overdose  rates  by  state  
  • 11. 11   736  out  of  86,818  prescribers  
  • 12. 12   42  out  of  one  million  prescribers  
  • 13. Overcorrect.  v.  To  correct   something  to  an  excessive  or   unusual  degree.   13
  • 14. 2014  State  legisla;ve  trends   14  
  • 15. Educa;onal  opportuni;es   15
  • 16. 16  
  • 17. Mandatory                    Educa5on   17  
  • 18. Enhancing  educa;on   18  
  • 19. Enhancing  educa;on   •  What  happens  medical  school/residency?   •  What  is  required  state-­‐by-­‐state?   •  Incen;vizing  educa;on  –  why  aren’t  there   more  to  help  treat  addic;on?   •  Just  what  do  we  mean/want  by  “specialist”?   19  
  • 20. The  AMA  interest  in  “pain”   •  Suppor;ng  legisla;on  to  combat  prescrip;on   drug  abuse  and  diversion   •  Enhancing  educa;on  and  appropriate  efforts   to  ensure  access  to  appropriate  pain   management     •  Increasing  access  to  treatment  for  substance   abuse  and  addic;on     20  
  • 21. 21
  • 22. Curbing  Prescrip;on  Drug  Abuse  and   Misuse:  Communica;ng  with  Providers-­‐ Best  Prac;ces  and  the  Role  of   Pharmacists     Catherine  Hanna,  RPh.  PharmD   KY  Board  of  Pharmacy   Vice  President  of  Professional  Affairs     American  Pharmacy  Services  Corpora;on  
  • 23. •  One  of  the  main  problems  health  care   professionals  see  when  having  difficulty   communica;ng  with  other  health  care   professionals  comes  down  to  knowledge,  respect   and  understanding  of  the  situa;on  at  hand  and   the  challenges  faced  by  each  other.   Improved  educa-on  and  communica-on  is   essen-al!   Improving  Communica;ons  Between   Health  Care  Professionals  
  • 24. •  Increased  focus  on  illness  and  deaths  caused   by  inappropriate  use  of  controlled   substances  —  in  par;cular  opioid  analgesics.     •  Opioid  prescrip;ons  have  increased   drama;cally  which  has  led  to  a  significant   increase  in  prescrip;on  drug  diversion,  abuse   and  misuse  and  a  substan;al  increase  in  the   number  of  deaths  due  to  overdose.         Why  We  are  Here?  
  • 25. •  In  the  mid-­‐1990s,  advocates  for  treatment  of   chronic  pain  began  arguing  that  pain  was  largely   untreated.   •  New  formula;ons  of  opioid  agents  became   available,  with  purported  advantages  in   analgesia.   •  Inappropriate  prescribing  has  also  increased   drama;cally.    Primarily  in  Pill  Mills     Why  We  are  Here?  
  • 26. •  Pharmacies  report  that  DEA  agents  are  inspec;ng   prescrip;ons  and  other  records.     •  DEA  agents  are  focusing  primarily  on  opiods  and   poly-­‐substance  prescribing,  large  doses  and  long-­‐ term  therapy.     •  DEA  agents  are  also  looking  for  red  flags  from   controlled  substance  data  and  prescriber’s   prescribing  paierns  and  the  prac;ce  site.       What  Is  Happening?  
  • 27. •  In  several  states  providers  have  reported  that  they  are   experiencing  problems  with  pharmacists  refusing  to  fill   pa;ent’s  controlled  substance  prescrip;ons.     •  Certain  pharmacies  reportedly  are  requiring  pa;ent   informa;on  such  as  diagnosis  codes,  treatment  history,   dura;on  of  therapy,    treatment  plans  and  payment  method   prior  to  filling  a  prescrip;on.     What  Is  Happening?  
  • 28. •  This  informa;on  is  not  required  by  state  or   federal  law  but  the  DEA  inves;ga;on  and   discipline  process  have  prompted  changes  in   some  pharmacy  policies.     •  Federal  privacy  laws  permit  doctors  to  share   pa;ent  informa;on  for  treatment  purposes   with  pharmacists.       What  Is  Happening?  
  • 29. •  Verifica;on  of  addi;onal  requested  informa;on   may  take  extra  ;me  on  the  part  of  the  prescriber.     Is  this  informa;on  necessary  to  fulfill  the  role  of   the  pharmacist  in  reducing  the  poten;al  abuse  of   controlled  substances?   •  A  pharmacist  can  refuse  to  fill  a  prescrip;on  if   professional  judgment  suggests  the  prescrip;on   is  in  viola;on  of  federal  or  state  law,  would  not  be   in  the  best  interest  of  the  pa;ent,  or  is  being   used  to  con;nue  an  addic;on  or  habit.   What  Is  Happening?  
  • 30. •  Pharmacies  have  a  role  to  play  in  the  oversight  of   prescrip;ons  for  controlled  substances.  Under   the  Controlled  Substances  Act,  pharmacists  must   evaluate  each  controlled  substance  prescrip;on   to  ensure  that  it  is  appropriate.   •  State  boards  of  pharmacy  regulate  the   distribu;on  of  opioids  and  other  controlled   substances    as  mandated  by  state  and  federal   regula;ons.           Understanding  the  Pharmacists   Liability  
  • 31. •  In  the  majority  of  cases  of  poten;al  abuse,   pharmacists  face  a  pa;ent  who  has  a  legal   prescrip;on  from  a  licensed  prescriber  without   actually  having  access  to  pa;ent  background   informa;on.     •  This  can  make  it  difficult  for  the  pharmacist   because  they  may  not  always  have  all  the   informa;on  they  need  to  make  an  completely   informed  decision  and  must  rely  on  their  “gut”  in   some  situa;ons.   Understanding  the  Pharmacists   Liability  
  • 32. •  Corresponding  responsibility  is  one  of  the   most  commonly  misunderstood  and  in  some   cases  unknown  concepts  found  in  DEA’s   regula;ons.     •  Enforcement  ac;ons  are  generally  ini;ated   against  pharmacists  and  pharmacies  when  a   pharmacist  fails  to  exercise  his/her   corresponding  responsibility.     Corresponding  Responsibility  
  • 33. •  The  DEA’s  regula;ons  (21  C.F.R.  §  1306.04)  addressing   corresponding  responsibility  states:   –  A  prescrip;on  for  a  controlled  substance  to  be  effec;ve  must  be  issued   for  a  legi;mate  medical  purpose  by  an  individual  prac;;oner  ac;ng  in   the  usual  course  of  his  professional  prac;ce.  The  responsibility  for  the   proper  prescribing  and  dispensing  of  controlled  substances  is  upon  the   prescribing  prac;;oner,  but  a  corresponding  responsibility  rests  with   the  pharmacist  who  fills  the  prescrip;on.     –  An  order  purpor;ng  to  be  a  prescrip;on  issued  not  in  the  usual  course   of  professional  treatment  or  in  legi;mate  and  authorized  research  is   not  a  prescrip;on  within  the  meaning  and  intent  of  sec;on  309  of  the   Act  (21  U.S.C.  829)  and  the  person  knowingly  filling  such  a  purported   prescrip;on,  as  well  as  the  person  issuing  it,  shall  be  subject  to  the   penal;es  provided  for  viola;ons  of  the  provisions  of  law  rela;ng  to   controlled  substances.   Corresponding  Responsibility  
  • 34. •  What  does  this  mean?    The  regula;on  states  that   the  pharmacist  is  in  the  same  posi;on  as  the   prescriber    who  issued  the  prescrip;on  and  must   exercise  professional  judgment  to  determine   whether  a  prescrip;on  for  a  controlled  substance   was  issued  for  a  legi;mate  reason  and  to  a   legi;mate  pa;ent.   •  Problem  in  the  eyes  of  the  pharmacist:    without   having  actually  conducted  a  medical  examina-on   of  the  pa-ent     Corresponding  Responsibility  
  • 35. •  DEA  has  made  it  clear  that  pharmacists  must   iden;fy  and  resolve  certain  red  flags  before  a   prescrip;on  for  a  controlled  substance  is   dispensed.       Corresponding  Responsibility  
  • 36. •  Does  iden;fying  red  flags  mean  you  are  exercising  your   corresponding  responsibility  as  required?     •  Are  pharmacists  exercising  corresponding   responsibility  appropriately  when  they  decide  not  to   dispense  controlled  substances  to  a  pa;ent  whose   prescrip;on  sets  off  one  or  more  red  flags?     •  How  many  red  flags  of  what  combina;on  of  red  flags   must  be  iden;fied  for  a  pharmacist  to  refuse   dispensing  a    prescrip;on?     Corresponding  Responsibility  and  the   Red  Flags  Ques;ons  
  • 37. •  The  pharmacist  can  not  simply  defer  to  the  prescriber   and  is  expected  to  exercise  independent  professional     judgment  when  determining  if  a  prescrip;on  was   issued  for  a  legi;mate  purpose  by  a  prescriber  ac;ng  in   the  usual  course  of  professional  judgment.       •  Merely  contac;ng  the  physician  for  verifica;on  that   the  prescrip;on  was  wriien  by  that  prescriber  may  not   be  sufficient  to  fulfill  the  pharmacist’s  duty,  and  the   pharmacist  should  refuse  to  fill  the  prescrip;on  if  there   is  reasonable  suspicion  that  it  is  not  valid.     Corresponding  Responsibility  and  the   Red  Flags  
  • 38. •  A  pharmacist  who  “knowingly”  fills  a  prescrip;on   that  is  not  issued  in  the  usual  course  of   professional  treatment  is  subject  to  the  penal;es   of  the  Controlled  Substance  Act.     •  The  pharmacist  who  decides  to  “look  the  other   way”  and  fills  a  prescrip;on  for  a  controlled   substance  that  he  or  she  knew  or  should  have   known  was  not  for  a  legi;mate  purpose  may  be   subject  to  prosecu;on.   Corresponding  Responsibility  and  the   Red  Flags  
  • 39. •  The  pharmacist  is  required  to  exercise  sound   professional  judgment  when  determining  the   legi;macy  of  a  prescrip;on  for  a  controlled   substance.     Corresponding  Responsibility  and  the   Red  Flags  
  • 40. •  “Paiern  prescribing’’  –  prescrip;ons  for  the  same  drugs  and  the  same   quan;;es  coming  from  the  same  doctor,  strengths/no  varia;on  in  the   quan;ty  and  strength  between  pa;ents     •  Prescribing  combina;ons  or  “cocktails”  of  frequently  abused  controlled   substances   •  Geographic  anomalies-­‐  A  prescriber’s  prescrip;on  paiern  is  different   from  that  of  other  prescribers  in  the  area  (e.g.,  more  prescrip;ons  for   controlled  substances  or  prescrip;ons  for  larger  quan;;es  of  controlled   drugs)     Red  Flags  May  Contain  
  • 41. •  Is  the  prescriber  not  familiar  to  the  pa;ent  or  is  the  provider  and/ or  the  pa;ent  from  out  of  town   •  Shared  addresses  by  customers  presen;ng  on  the  same  day   •  The  prescribing  of  controlled  substances  in  general     •  Quan;ty  and  strength-­‐large  quan;;es  and  strengths   •  Paying  cash  rather  than  using  insurance   •  Customers  with  the  same  diagnosis  code  from  the  same  doctor   Red  Flags-­‐con;nued  
  • 42. •  Prescrip;ons  wriien  by  doctors  for  infirmaries  not   consistent  with  their  area  of  specialty;   •  Fraudulent  prescrip;ons  or  prescrip;ons  with   irregulari;es   •  Pa;ent  is  asking  for  brand  name  only  or  a  certain   generic  brand     •  The  pa;ent  is  overly  friendly  or  nervous   Red  Flags-­‐con;nued    
  • 43. –  Prescriber  writes  for  antagonis;c  drugs  (e.g.,  s;mulant  and  depressant  at  the   same  ;me)     –  Pa;ent  returns  to  the  pharmacy  more  frequently  than  expected  (e.g.,   prescrip;on  quan;;es  do  not  last  as  long  as  expected)     –  Pa;ent  presents  mul;ple  prescrip;ons  for  the  same  drug  wriien  for  different   people   –  A  number  of  people  appear  within  a  short  ;me  period  for  the  same  controlled   drug  from  the  same  physician,  or  a  large  number  of  previously  unknown   patrons  show  up  with  prescrip;ons  from  the  same  physician     –  The  patron  presents  a  prescrip;on  that  shows  evidence  of  possible  forgery   (e.g.,  unusual  direc;ons  or  quan;;es,  no  abbrevia;ons,  apparent  erasures,   unusual  legibility,  evidence  of  photocopying)     Red  Flags  -­‐con;nued  
  • 44. •  The  abuse  and  misuse  of  prescrip;on  drugs  is  a  serious  problem   that  we  all  recognize,  but  has  the  response  by  law  enforcement  and   other  agencies  to  curb  diversion  created  challenges  when  balancing   the  need  for  treatment  of  legi;mate  pa;ents?   •  Are  we  seeing  an  environment  where  providers  are  reluctant  to   prescribe  and  pharmacists  are  reluctant  to  dispense  medica;ons  for   legi;mate  pa;ents?   •  How  can  the  professions  work  together  to  improve  communica;on   and  collaborate  toward  the  ul;mate  goal  to  curb  prescrip;on  drug   diversion,  abuse  and  misuse  and  insure  that  legi;mate  pa;ents  are   cared  for  appropriately?   Challenges  
  • 45. •  All  healthcare  providers  need  to  be  aware  of  the   poten;al  for  drug  diversion,  recognize  the  warning   signs  of  possible  misuse  and  abuse  and  acknowledge   the  legal  obliga;ons  we  all  have  to  minimize   improper  prescrip;on  use.     •  The  baile  to  prevent  prescrip;on  drug  abuse  while   maintaining  access  to  pa;ents  in  need  is  challenging,   but  both  professions  must  each  realize  the   responsibili;es    of  all  par;es  as  we  work  toward  a   solu;on.       Improving  Communica;ons  Between   Health  Care  Professionals  
  • 46. •  There  are  many  differences  between  the  professions  of   medicine  and  pharmacy  that  ul;mately  influence  our   understanding  of  the  other  profession.       •  It  is  clear  that  effec;ve,  deliberate  prescriber-­‐pharmacist   collabora;on,  improved  communica;on  and  working   rela;onships  can  significantly  improve  overall  pa;ent  care   and  help  curb  prescrip;on  drug  diversion,  abuse  and   misuse.     •  Efforts  to  improve  these  rela;onships  must  focus  on  the   strategic  introduc;on  of  agreed  changes  working  prac;ces   between  the  two  professions  and  educa;on.     Improving  Communica;ons  Between   Health  Care  Professionals  
  • 47. •  When  communica;ng  and  collabora;ng  to   improve  pa;ent  care  the  focus  must:     –  Place  the  overall  care  of  the  legi;mate  pa;ent  first   –  Incorporate  sound  clinical  knowledge   –  Incorporate  sound  professional  judgment   –  Allow  each  profession  to  act  in  a  collegial  and   collabora;ve  manner   –  Be  based  upon  understanding/knowledge  and  respect   of  the  role  and  obliga;ons  of  all  professionals  involved   Improving  Communica;ons  Between   Health  Care  Professionals  
  • 48. •  Stakeholder:  AMA,  NCPA,  NABP,  CVS,  Walgreens,  NACDS,  Rite   Aid,  American  Academy  of  Family  Physicians,  American   Osteopathic  Associa;on,  Cardinal  Health,  Pharmaceu;cal   Research  and  Manufacturers  of  America   •  Consensus  was  that  coordina;on  and  collabora;on  must  be   improved  to  combat  the  issue  of  prescrip;on  drug  abuse  and   diversion  while  also  complying  with  the  corresponding   responsibility  requirements  of  federal  and  state  laws  and   regula;ons.     Stakeholders  Consensus  Document  on  Prescribing  and   Dispensing  Controlled  Substances  
  • 49. Discussion  of  Strategies  
  • 50. P.  Tennent  Slack,  MD   Pain  Medicine  /  Anesthesiology   Dept.  of  Interven;onal  Pain  Medicine   Northeast  Georgia  Physicians  Group  
  • 51. P.  Tennent  Slack  has  no  financial  rela;onships  with   proprietary  en;;es  that  produce  health  care  goods  and   services  
  • 52. 1.  Outline  the  strategies  for  collabora;ng  across   professional  lines  for  the  adequate  treatment  of   pa;ents.     2.  Describe  best  prac;ces  for  prescribers  to   communicate  with  dispensers.     3.  Evaluate  the  challenges  for  health  care   professionals  in  communica;ng  about  their   pa;ents  and  offer  solu;ons.  
  • 53. Consequences  Of  Prescribers  Not  Engaging   •  Promotes  inaccurate  assump;ons  and  inaccurate   conclusions     –  Pharmacists   –  Law  enforcement   –  Government  officials   –  Interested  organiza;ons  –  CDC,  NADDI,  etc.   –  The  public  at  large   •  Erosion  of  physician  control  over  decisions  that  are   fundamentally  medical  in  nature    
  • 54. The  Pain   Treatment   Environment   Elements  of   Discrimina;ng   Prescribing   Opioid   Rx  
  • 55. The  Pain  Treatment  Environment  
  • 56. THE  PERFECT  STORM   Pain   •  Pain  complaints  are  extremely   common   •  Mind-­‐body  phenomenon   •  Subjec5ve   •  Difficult  to  measure   •  High  inter-­‐individual  variability   –  Gene5cs   –  Environment  /  culture   •  Mood/anxiety  disorders   Opioids   •  Single  most  effec5ve   medica5on  for  moderate-­‐ severe  pain   •  High  addic5on  liability   •  High  inter-­‐individual   variability   –  Pharmacogene5cs   –  Cultural  /  environmental   –  Socioeconomic  status  
  • 57. More   control   Less  control   Ability  to   downregulate  use   Addic5on   “Legi5mate”  use       “Chemical  coping”   Opioid  use  -­‐  misuse  spectrum   4  C’s   1.  Loss  of  control   2.  Compulsive   use   3.  Con5nued  use   despite  harm   4.  Craving  
  • 58. Compassion   Cynicism  
  • 59. MAJOR  CONCERNS  OF  OPIOID  PRESCRIBERS   %   Poten5al  abuse  /  addic5on     89  %   Diversion   75  %   Opioid  side  effects   53  %   Regulatory  /  law  enforcement  monitoring   40  %   Hassle  and  5me  required  to  track/  refill   28  %   Upshur  CC  et  al.  J  Gen  Intern  Med  2006  
  • 60. “Red  Flags”   •  “Urgency”  when  reques;ng  need  for  opioids   •  Pa;ent  reports  side  effects  /  lack  of  efficacy  to  wide  variety   of  non-­‐opioid  /  opioid-­‐sparing  treatments     •  Friday  arernoon  /  weekend  requests  for  medica;on  or   medica;on  changes   •  Repeated  requests  for  the  following:    early  refill        dose  and/or  pill  volume  escala;on    above  requests  in  the  face  of  missed  follow  up   •  Pa;ent  reports  lost  or  stolen  prescrip;on  
  • 61. “Red  Flags”  cont.   •  Poor  correla;on  between  complaints,  physical  exam,  and/or   imaging  studies,  etc.   •  “Inability”  or  refusal  to  provide  urine  sample  for  drug   screening  purposes   •  Drug  screen  posi;ve  for  unreported  controlled  substances   and/or  illicit  drugs  
  • 62. “New”  GA  State  Medical  Board  Pain  Management  Rules  
  • 63. The  Pain   Treatment   Environment   Elements  of   Discrimina;ng   Prescribing   Opioid   Rx  
  • 64. Elements  of  Discrimina;ng  Prescribing   Numerous  opioid  prescribing  guidelines     •  medical  socie5es  /  organiza5ons;  states;  etc.   •  No  single  defini5on  for  “best  prac5ces”   1.  Thorough  Evalua5on   2.  Prudent  Treatment  Plan   3.  Vigilant  Follow  Up  
  • 65. Overview  of  Prescribers   All  other  prescribers   More   discrimina;ng   Less   discrimina;ng   The  “Pill  Mill”  Prescriber  
  • 66. Common“Pill  Mill”  Characteris;cs   •  Nearly  exclusive  associa;ons  with  specific  pharmacies     •  Physicians  with  minimal  or  no  training  in  pain  medicine   •  Cash-­‐based  payment     •  Large  volume  of  pa;ents  seen  daily  (100  +)     •  Unusually  large  volume  of  pa;ents  from  out  of  state   •  Security  guards  on  site   •  Non-­‐tradi;onal  prac;ce  loca;on  –  e.g.  shopping  center   •  Minimal  pa;ent  work-­‐up   •  Lihle  varia5on  in  choice  of  opioid  or  pill  volume   •  Opioids  very  frequently  prescribed  simultaneously  with   benzodiazepines  and/or  carisoprodol   •  High  dosages  /  high  pill  volumes   Sources:  DEA;  NADDI  
  • 67. The  University  of  Wisconsin  School  of  Medicine  and  Public  Health’s  Pain   and  Policy  Studies  Group  (PPSG)  awarded  Georgia  a  grade  of  “A”  for  its   pain  management  policies  in  2012,  marking  the  largest  improvement  in   the  na;on  from  2006  to  2012.  
  • 68. 1.  How  definable  is  the  source  of  pain?   2.  Screen  for  risk  of  addic;on   3.  Explore  all  treatment  op;ons   4.  If  opioids  are  prescribed:  lowest  effec;ve  dose  lowest   number  of  pills   5.  Educate  the  pa;ent    risks/benefits  of  opioid  use   i.  sharing  opioid  medica;ons  is  ILLEGAL   ii.  proper  storage  and  disposal   6.  Monitor  the  pa;ent  for  misuse  /  diversion   i.  controlled  substances  agreement   ii.  drug  screening  /  pill  counts   iii.  PDMP   6  Point  Checklist  to  More  Discrimina;ng  Prescribing  
  • 69. The  Inescapable  Slippery  Slope   •  Defining  that  which  does  not  have  a  single   defini;on:   – “pain”   – “valid”;  “legi;mate”   – “red  flags”   – “best  prac;ces”  

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