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

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Ph 1 harris hanna_slack

  1. 1. Pharmacy  Track:    Improving  Communica5ons   with  Physicians     Patrice  A.  Harris,  MD   Catherine  Hanna,  RPh.  PharmD   P.  Tennent  Slack,  MD  
  2. 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. 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. 4. America’s  Rx  drug  abuse     and  diversion  crisis   Patrice A. Harris, MD National Rx Drug Abuse Summit April 2014
  5. 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. 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. 7  
  8. 8. NO     Pain   NO     Gain   8  
  9. 9. 9
  10. 10. 10 Drug  overdose  rates  by  state  
  11. 11. 11   736  out  of  86,818  prescribers  
  12. 12. 12   42  out  of  one  million  prescribers  
  13. 13. Overcorrect.  v.  To  correct   something  to  an  excessive  or   unusual  degree.   13
  14. 14. 2014  State  legisla;ve  trends   14  
  15. 15. Educa;onal  opportuni;es   15
  16. 16. 16  
  17. 17. Mandatory                    Educa5on   17  
  18. 18. Enhancing  educa;on   18  
  19. 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. 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. 21
  22. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 49. Discussion  of  Strategies  
  50. 50. P.  Tennent  Slack,  MD   Pain  Medicine  /  Anesthesiology   Dept.  of  Interven;onal  Pain  Medicine   Northeast  Georgia  Physicians  Group  
  51. 51. P.  Tennent  Slack  has  no  financial  rela;onships  with   proprietary  en;;es  that  produce  health  care  goods  and   services  
  52. 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. 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. 54. The  Pain   Treatment   Environment   Elements  of   Discrimina;ng   Prescribing   Opioid   Rx  
  55. 55. The  Pain  Treatment  Environment  
  56. 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. 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. 58. Compassion   Cynicism  
  59. 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. 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. 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. 62. “New”  GA  State  Medical  Board  Pain  Management  Rules  
  63. 63. The  Pain   Treatment   Environment   Elements  of   Discrimina;ng   Prescribing   Opioid   Rx  
  64. 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. 65. Overview  of  Prescribers   All  other  prescribers   More   discrimina;ng   Less   discrimina;ng   The  “Pill  Mill”  Prescriber  
  66. 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. 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. 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. 69. The  Inescapable  Slippery  Slope   •  Defining  that  which  does  not  have  a  single   defini;on:   – “pain”   – “valid”;  “legi;mate”   – “red  flags”   – “best  prac;ces”