HOW THE EPIDEMIC OF ADDICTION IS RIPPLING THROUGH … · ¡Working in harm reduction model through Risk Mitigation Practices (RMP) ... Michael Wright, RPh. DISCLOSURES ¡I have no

HOW THE EPIDEMIC OF ADDICTION IS RIPPLING THROUGH PROFESSIONS

ZACHARY HILL, PHARMD, MA

CLINICAL PHARMACY SPECIALIST- MENTAL HEALTH

SERVICES FOR OUTPATIENT ADDICTION RECOVERY (SOAR)

VA SALT LAKE CITY HEALTH CARE SYSTEM

DISCLOSURES

¡ I have no disclosures to make.

OBJECTIVES

¡ Discuss how practice standards and expectations of professionals dealing with addiction has changed in recent years- namely how pharmacists have adapted in an interdisciplinary sense

¡ Demonstrate how pharmacists and other professionals may encounter ethical dilemmas as their scope of practice has changed

¡ Balancing ethics with responsibilities to employers, other professionals in conflicts

EPIDEMIOLOGY

EPIDEMIOLOGY

TO ADDRESS: WHY PHARMACISTS?

¡ Pharmacists are in unique position in healthcare to affect change in addiction¡ Vital role in dispensing and supply chain

¡ Extensive training/background in being “medication experts”

¡ Involved in legislation affecting prescribing/dispensing policies

Chisholm-Burns, M et al. Opioid Crisis. 2019.

GUIDANCE ON PHARMACY INTERVENTIONS

¡ Key interventions outlined for hospital/health system pharmacists¡ Distribution of naloxone kits for overdose prevention in addition to

training on proper use with Teach Back

¡ Participation in provision of medication-assisted treatment (MAT)

¡ Provision of medication reviews and reconciliation

¡ Referring appropriate patients to addiction treatment services



¡ Working in harm reduction model through Risk Mitigation Practices (RMP)

¡ Querying Prescription Drug Monitoring Programs (PDMPs)

¡ Developing and ensuring use of prescription pain contracts outlining education/risks of chronic opioid use

¡ Ordering/interpreting urine drug screens for patients on MAT or opioid therapy



¡ Providing interdisciplinary education taking the form of several measures at the Veterans’ Affairs¡ Clinical pharmacists conduct Opioid Database Risk Reviews based upon Stratified Tool for Opioid

Risk Management (STORM) data

¡ Clinical pharmacists provide academic detailing to providers that allow comparisons of prescribing habits for education

¡ Detail incoming residents to VAMC medical system on how to identify problematic opioid taking behavior + prescribe naloxone

¡ Provide continuing education (CE) for interdisciplinary teams through Grand Rounds (monthly to bimonthly basis)


VETERANS’ AFFAIRS SPECIFIC INITIATIVES

¡ STORM as a VA specific RMP¡ Real-time updating daily¡ Provides risk estimate for those with opioid use or other co-occurring

polysubstance use disorders¡ Overdose risk or suicide¡ Both opioid prescription dependent and non-opioid prescription dependent

values¡ Incorporates biopsychosocial factors for total picture

Olivia EM, et al. STORM. 2017.

Olivia E, et al. STORM. 2017.

VETERANS’ AFFAIRS SPECIFIC INITIATIVES¡ Risk Index for Overdose or Serious Opioid-Induced Respiratory

Depression- (RIOSORD)¡ Validated previously with Veterans Health Administration¡ Multivariable logistic regression to define specific factors¡ Case control analysis of > 18 million patients from 2009-2013¡ Data was able to accurately predict opioid-induced respiratory depression

(OIRD)¡ Strong data-driven decision support tool for assessing risk

Zedler BK, et al. Validation. 2018.



VETERANS’ AFFAIRS SPECIFIC INITIATIVES

¡ Academic Detailing¡ Clinical pharmacists provide education regarding prescribing practices

¡ Utilize data driven analytics to compare prescribing habits

¡ Work collaboratively with physicians to improve prescribing parameters and lower risk to patients

¡ Study examining this showed several key factors improved, é PDMP searches, é urine drug screens ordered, é satisfaction of care by patients

Larson M, et al. Safer Opioid. 2018.

BARRIERS/DILEMMAS WITHIN INTERVENTIONS

¡ PDMP searches are vital part but how to balance roles of relationship with monitoring?¡ Issue found- how to broach topic with patient while maintaining rapport¡ Which is more valuable? Preventing further diversion or keeping patient engaged in

treatment?

¡ Opinions of MAT¡ Some pharmacists may still hold beliefs this is trading one substance for another

¡ May refuse to fill patient prescriptions for OUD medication¡ Stigma/beliefs about substance use may affect care provided to patients

Hamilton K. Opioid world. 2018.


¡ Pharmacists are not licensed independent practitioners¡ Do not diagnose

¡ Interact with providers who do diagnose but are not comfortable treating addiction

¡ How do we as pharmacists bridge the gap between?


¡ Pharmacists are trained in being able to identify various mood/mental health concerns¡ Versed in matching medication to diagnosis for management

¡ Difference between recognizing criteria listed vs. patient presentation

¡ Can design interviews with specific questions to obtain valuable diagnostic information for LIPs

SOLUTIONS TO BREAK DOWN BARRIERS

¡ Pharmacists are still valuable members of interdisciplinary teams¡ Educate ourselves on how to best match interventions for specific patients

¡ Consult with providers as a team for joint decisions

¡ Design and present outreaches in community clinics to assist LIPs in their decision making process for the most beneficial patient outcomes

ADDICTION IN PHARMACY PROFESSION

¡ Pharmacists Recovery Network (PRN)

¡ Rates of substance abuse for medical professionals ~ lay public

¡ Rates of prescription drug abuse > street sources for pharmacists

¡ Factors- high stress, greater access

¡ PRN is national network connecting state agencies

Milenkovich N. Impaired Pharmacist. 2013.


¡ Pharmacists Recovery Network (PRN)¡ Referrals through State Board of Pharmacy

¡ Assigned counselor to coordinate care

¡ Random urine drug screens

¡ Group meeting participation at regular intervals

¡ Lifetime monitoring is an option/condition for reinstatement of license

¡ Programs vary on state by state basis

Milenkovich N. Impaired Pharmacist. 2013.


¡ Utah Recovery Assistance Program¡ Provided through Utah Division of Occupational and Professional Licensing

(DOPL)

¡ Options to self-report or report concern for another individual

¡ Example Practice Plan Guidelines available online at: https://dopl.utah.gov/programs/urap/

¡ Lists for Professionals in Recovery (PIR) groups throughout state of Utah available

DOPL. 2019.

https://dopl.utah.gov/programs/urap/

LEGISLATION EFFORTS

¡ H.R. 3991 Expanded Access to Opioid Abuse Treatment Act of 2017¡ Bill would give pharmacists the right to obtain DATA waivers to prescribe buprenorphine

as mid-level practitioners

¡ Six states allow pharmacists to prescribe CII-CIV medications but not this particular CIII medication

¡ Reasons being- “medication expert” with 6-8 years of college training, most based on medications

¡ Sponsors felt this could address gap in prescribers¡ Last update 10-16-2017- Referred to Subcomittee on Crime, Terrorism, Homeland

Security, and Investigations and expired

115th Congress. H.R. 3991. 2017.

EXPANSION OF PHARMACY ROLES¡ Development and establishment of clinical pharmacists as controlled

substance/vault point person¡ Main goals

¡ Prevent diversion ¡ Set a perpetual inventory¡ Increase accountability with pharmacy provision

¡ Meeting guidelines for “corresponding responsibility” for pharmacists in ensuring controlled substances dispensed appropriately

ASHP. Preventing diversion. 2017.

EXPANSION OF PHARMACY ROLES¡ Integration of clinical pharmacists into chronic pain care role

¡ Reviewing medication regimens and working in interdisciplinary manner to provide sound recommendations

¡ Involving clinical pharmacists in prescribing roles in outpatient addiction treatment¡ Position in Services for Outpatient Addiction Recovery under Addiction Treatment Services

(SOAR)¡ Scope of practice to prescribe mental health medications and MAT¡ Provide bridge/access appointments along with follow-up to meet veterans where they are in

ambivalence around change

ASHP. Preventing diversion. 2017.

EXPANSION OF PHARMACY ROLES

¡ Clinical Pharmacist Position in SOAR¡ Design new workflows to increase access/break down barriers to treatment¡ On-site dispensing of naloxone kits to intakes for high risk patients¡ Clinic administration of naltrexone LAI for patients to meet their level of

readiness to change¡ Future- design workflow, storage, policy for buprenorphine LAI for opioid

use disorder


¡ Clinical Pharmacist Position in SOAR¡ Provide education on options of treatment and act as screen to connect to

services¡ Enter consults to access other aspects of VA medical care and opioid replacement

therapy with appropriate referral¡ Precept pharmacy residents and students to guide the next clinicians¡ Track a population to prevent “falling through the cracks” via Care Management

Tool


¡ Clinical Pharmacist Position in SOAR¡ Utilize Measurement Based Care tools such as PHQ-9, GAD-7, and Brief Addiction

Monitor (BAM)

¡ Screen patients for suicidality and utilize Columbia- Suicide Severity Rating Scale (C-SSRS) to determine need for escalation of care/evaluation

¡ Positive screens on C-SSRS are escalated to licensed independent provider

¡ Communication with crisis workers to coordinate SI evaluation in ER

Scott K. MBC. 2015.

CONCLUSIONS

¡ Pharmacists have made many adaptations to affect positive change in the addiction epidemic

¡ Increased prescriptive authority, diversification of roles, and greater involvement in data analytics are just a few examples

¡ Increasing access to substance use services and decreasing diversion are keys

¡ Pharmacists will continue to act as the safety net, the academic detailer, and/or the medication expert to help stem the tide

WE’RE HERE TO MAKE THE HARD CHOICES –ETHICAL QUESTIONS WITH OPIOIDS

Michael Wright, RPh

DISCLOSURES

¡ I have no disclosures in regards to this presentation.

OATH OF A PHARMACIST

"I promise to devote myself to a lifetime of service to others through the profession of pharmacy. In fulfilling this vow:

¡ I will consider the welfare of humanity and relief of suffering my primary concerns.

¡ I will apply my knowledge, experience, and skills to the best of my ability to assure optimal outcomes for my patients.

¡ I will respect and protect all personal and health information entrusted to me.

¡ I will accept the lifelong obligation to improve my professional knowledge and competence.

¡ I will hold myself and my colleagues to the highest principles of our profession’s moral, ethical and legal conduct.

¡ I will embrace and advocate changes that improve patient care.

¡ I will utilize my knowledge, skills, experiences, and values to prepare the next generation of pharmacists.

I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public.”

PHARMACY CODE OF ETHICS¡ I. A pharmacist respects the covenantal relationship between the patient and pharmacist

¡ II. A pharmacist promotes the good of every patient in a caring, compassionate, and confidential manner

¡ III. A pharmacist respects the autonomy and dignity of each patient

¡ IV. A pharmacist acts with honesty and integrity in professional relationships

¡ V. A pharmacist maintains professional competence

¡ VI. A pharmacist respects the values and abilities of colleagues and other health professionals

¡ VII. A pharmacist serves individual, community, and societal needs

¡ VIII. A pharmacist seeks justice in the distribution of health resources

Adopted by the membership of APhA October 27, 1994

REALITIES

¡ Pharmacy only gets paid when it dispenses

¡ Increased scrutiny from DEA and suppliers

¡ Pharmacy jobs are at a premium

¡ Pharmacy moves very fast

¡ Prescribers are busy and difficult to get ahold of

¡ Pharmacists do not think as a group anymore than any other group does

¡ There is no good and fast way to tell who the bad players are

THREE DIFFERENT REASONS TO WANT AN OPIOID PRESCRIPTION

DILEMMA

¡ A prescriber’s office has a pattern of questionable prescribing. You have reported it to the DEA, but there are no results as of yet. How do you deal with their prescriptions?

DILEMMA

¡ A prescriber’s office has a pattern of questionable prescribing. You have reported it to the DEA, but there are no results as of yet. How do you deal with their prescriptions?

DILEMMA

¡ Patient presents a prescription, but the doctor forgot to sign it. The office is closed and the patient needs the medication.

DILEMMA

¡ The pharmacy down the street calls you to let you know they refused to fill a patient’s prescription and encourages you to do the same.

DILEMMA

¡ Your pharmacy has a policy that over a certain MME, a patient must also have naloxone. The patient can’t afford naloxone and their insurance won’t pay for it.

DILEMMA

¡ Your colleague refuses to fill a prescription. The patient asks for you and explains the situation. You feel that it would be appropriate to fill the prescription.

DILEMMA

¡ A prescriber informs you they have cut a patient off because they caught them selling their medication.

DILEMMA

¡ A patient drops off a prescription that you confirm is a forgery. Your company’s policy states that you return the prescription to the patient and not call the police.

DILEMMA

¡ In talking with a prescriber, they state they are fine with a patient taking an extra tablet here or there, but they refuse to write the prescription according to those instructions.

DILEMMA

¡ The prescriber has authorized early fills for the last four months without a corresponding reason.

DILEMMA¡ A patient presents a prescription for oxycodone 30 #240. In searching

the database today, you find this:

Date Drug # Days

3/2/2019 Oxycodone 30 240 30

2/1/2019 Oxycodone 30 240 30

1/3/2019 Oxycodone 30 240 30

12/5/2018 Oxycodone 30 240 30

11/6/2019 Oxycodone 30 240 30

DILEMMA¡ A patient presents a prescription for oxycodone 30 #240. In searching

the database today, you find this:

Date Drug # Days

5/17/2019 Oxycodone 30 240 30

4/20/2019 Oxycodone 30 240 30

4/1/2019 Oxycodone 30 240 30

3/5/2019 Oxycodone 30 240 30

2/6/2019 Oxycodone 30 240 30

1/16/2019 Oxycodone 30 240 30

DILEMMA

¡ You have 3 prescriptions from the same prescriber for diazepam 10, 1 QID; carisoprodol 350, 1 QID, and oxycodone 30, 1 Q4H. You contact the prescriber with concerns about the combination of a benzo, muscle relaxant, and opioid and their response is the dangers are overstated and this is what they want.

DILEMMA

¡ As a small independent pharmacy you have primarily cash paying customers. You look at your price on buprenorphine and mark it up to make a profit, but still be accessible to cash paying customers, which puts you at about ¼ of the price of your local competitors. You start getting an influx of customers who have their other prescriptions at competitors, but come to you for your price on buprenorphine.

DILEMMA

¡ A retired doctor’s wife is on large doses of opioids from another prescriber. He prescribes gabapentin for his wife.

QUESTIONS?

REFERENCES¡ Access data table for Figure 4 at: https://www.cdc.gov/nchs/data/databriefs/db329_tables-508.pdf#4. SOURCE: NCHS, National Vital Statistics

System, Mortality.

¡ Hedegaard H, Miniño AM, Warner M. Drug overdose deaths in the United States, 1999–2017. NCHS Data Brief, no 329. Hyattsville, MD: National Center for Health Statistics. 2018.

¡ Hamilton KE. Living in an opioid world: the pressing need for improved substance use disorder education (December 11, 2018). https://cptl-pulses.com/2018/12/11substance-use-disorder-education/(accessed 2019 May 21).

¡ Marie A Chisholm-Burns, Christina A Spivey, Erin Sherwin, James Wheeler, Kenneth Hohmeier, The opioid crisis: Origins, trends, policies, and the roles of pharmacists, American Journal of Health-System Pharmacy, Volume 76, Issue 7, 1 April 2019, Pages 424–435.

¡ Lewis E. Data-based case reviews of patients with opioid related risk factors as a tool to prevent overdose and suicide. HSR&D Center for Innovation to Implementation. Available at: https://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/2488-notes.pdf.

¡ Oliva EM, Bowe T, Tavakoli S, Martins S, Lewis ET, Paik M, Wiechers I, Henderson P, Harvey M, Avoundjian T, Medhanie A, Trafton JA. Development and applications of the Veterans Health Administration's Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide. Psychol Serv. 2017 Feb;14(1):34-49.

¡ Zedler BK, Saunders WB, Joyce AR, Vick CC, Murrelle EL. Validation of a Screening Risk Index for Serious Prescription Opioid-Induced Respiratory Depression or Overdose in a US Commercial Health Plan Claims Database. Pain Med. 2018;19(1):68–78.

https://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/2488-notes.pdf

REFERENCES¡ Larson MJ, Browne C, Nikitin RV et al. Physicians report adopting safer opioid prescribing behaviors after academic detailing intervention.

Subst Abus. Epub ahead of print. 2018 May 4.

¡ Rosenberg-Yunger ZRS, Ellen M, Mickleborough T. The North American opioid experience and the role of community pharmacy. J Public Health Manag Pract. 2018; 24: 301-305.

¡ Ned Milenkovich (2013) The impaired pharmacist: Rehabilitation, regaining dignity and licensure. Mental Health Clinician: December 2013, Vol. 3, No. 6, pp. 313-315.

¡ Utah Division of Occupational & Professional Licensing. Pharmacists Recovery Network. Available at: https://dopl.utah.gov/programs/urap/ . Access May 21, 2019.

¡ H.R. 3991- 115th Congress: Expanded Access to Opioid Abuse Treatment Act of 2017. Statement for Record- To the House Energy & Commerce Committee Hearing: “Federal Efforts to Combat the Opioid Crisis: A Status Update on CARA and Other Initiatives”. American Pharmacists Association (APhA). Available at: https://pharmacist.com/sites/default/files/audience/Joint%20Statement%20for%20the%20Record%20on%20%20MAT%20to%20Energy%20and%20Commerce%20Hearing_10_25_2017.pdf. October 27, 2017.

https://dopl.utah.gov/programs/urap/

REFERENCES

¡ American Society of Health-System Pharmacists. ASHP guidelines on preventing diversion of controlled substances. Am J Health-Syst Pharm. 2017; 74:325-48. 100 Drug Distribution and Control–Guideline.

¡ Scott K, Lewis CC. Using Measurement-Based Care to Enhance Any Treatment. Cogn Behav Pract. 2015;22(1):49–59

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HOW THE EPIDEMIC OF ADDICTION IS RIPPLING THROUGH … · ¡Working in harm reduction model through Risk Mitigation Practices (RMP) ... Michael Wright, RPh. DISCLOSURES ¡I have no