Take Action against the Opioid Epidemic: No Need to Wait for Congress

Friday, July 22, 2016

Marsha K. Millonig, MBA, BPharm

It seems that you can’t go a day without seeing or hearing something about the opioid epidemic, whether in trade publications or mainstream media.

But now that everyone is paying attention to it, what happens?

The Centers for Disease Control (CDC) published guidelines, Congress wants new laws, the DEA is focused on diversion, providers want to take care of patients. One of my previous blog posts addressed the White House’s recent initiative. While these wheels turn, I thought it would be helpful to review some practical steps you might take right now to be proactive in addressing the issue. Instead of waiting for Congress!

Take Action in the Pharmacy

If you aren’t already connected to your state’s prescription drug monitoring program (PDMP), that’s something you’ll want to do!

Once you’re connected, make sure you have consistent policies for checking the database and taking any subsequent action. Some states have requirements for when prescribers and pharmacists have to check the PDMP — some as often as every prescription or fill. Vendors are starting to develop ways to automate that check, so it’s integrated into workflow. This functionality will allow for consistency, which will improve practice.

Some states have implemented an enhanced methodology that allows for a score to be associated to the patient’s records. This score can offer providers a sense of the potential risk associated with a patient’s use, as it uses an algorithm to analyze opioid and sedative fill data.

The CDC guidelines, published earlier this year, are worth reviewing. Although these are primarily targeted toward prescribers, several can be applied by other care providers, such as the risk assessment recommendations that follow:

“8. Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use, are present.

9. Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.”

Lowell Anderson, a Minnesota pharmacist and co-director of the University of Minnesota’s Center for Leading Healthcare Change, recently wrote an article for MinnPost in which he acknowledges the complexity of our current legal and financial systems surrounding narcotics. He proposes pharmacist-forward approaches to managing opioids, including:

  • Allowing pharmacists to manage the quantities dispensed
  • Getting payers to adjust their claims processing methodologies accordingly.

There may be ways to work with the prescribers and payers in your community to implement some of his suggestions, while remaining in compliance with all regulatory requirements.

Clearly, one of the great fears associated with opioid use is the risk of overdose. Until some of the other recommendations are implemented that would reduce the risk potential, we must consider how to address the inevitable overdose situation.

There are efforts underway in many states to allow for the dispensing of naloxone without a prescription. Contact your state pharmacist association or Board of Pharmacy to validate what’s allowable in your jurisdiction. Every day it seems more activity is happening on the naloxone front. Both entities may also be a good resource for other activities that would benefit from pharmacist participation.

Take Action in the Larger Healthcare Community

Joseph Bianco, MD, FAAFP, Chief of Primary Care at Essentia Health, while presenting at the Minnesota Rural Health Conference in June, stated that since prescribers helped create the situation, they need to be part of the solution. Essentia has implemented new processes related to opioid prescribing, including use of evidence-based guidelines, treatment agreements, limits on daily morphine dose equivalents, and new metrics to monitor the impact of these changes. They’ve seen tremendous progress, with 12% fewer primary care patients on chronic opioid treatment in 2016 alone.

If you’re a pharmacist participating in collaborative practice agreements or in accountable care organizations, talk with your prescribing partners about how you can assist them in managing their chronic opioid patients. Understand the messages they’re sharing with the patients so that you can reinforce those. Even if you’re not operating under a formal agreement, prescribers may be receptive to your professional observations and recommendations.

There are likely community-based activities, either through care systems or county public health departments, in which additional involvement is needed. These activities could include:

  • Participating in panel discussions
  • Engaging with drug abuse task forces
  • Partnering with law enforcement for educational programs such as D.A.R.E. (Drug Abuse Resistance Education)

I have served on the Minnesota D.A.R.E. board since the Minnesota Pharmacist’s Association first became involved in building awareness of opioid abuse in 2007. Those early efforts morphed into what is now the National Association of Boards of Pharmacy AwareRx program and Cardinal Health’s Generation Rx program. Both are supportive of D.A.R.E.’s continuing efforts to educate adolescents, and I encourage pharmacists to become involved. Law enforcement officers have noted their experience with illicit substances can be quite different than dealing with prescription drug abuse, and they need help understanding how to approach these cases. It’s an area in which pharmacists can play an important role.

Marsha K. Millonig, MBA, BPharm, is president and CEO of Catalyst Enterprises, LLC, and an Associate Fellow at the University of Minnesota College of Pharmacy’s Center for Leading Healthcare Change.

Want to learn more about related topics? Check out these RxPerts Academy features on opioid prescribing and dispensing:

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