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

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

57. The
Pain
Treatment
Environment
Elements
of
Discrimina;ng
Prescribing
Opioid
Rx

58. The
Pain
Treatment
Environment

59. 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

60. 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

61. Compassion
Cynicism

63. 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

64. “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

65. “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

66. “New”
GA
State
Medical
Board
Pain
Management
Rules

67. The
Pain
Treatment
Environment
Elements
of
Discrimina;ng
Prescribing
Opioid
Rx

68. 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

69. Overview
of
Prescribers
All
other
prescribers
More
discrimina;ng
Less
discrimina;ng
The
“Pill
Mill”
Prescriber

70. 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

71. 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.

72. 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

73. The
Inescapable
Slippery
Slope
• Defining
that
which
does
not
have
a
single
defini;on:
– “pain”
– “valid”;
“legi;mate”
– “red
flags”
– “best
prac;ces”