PMC Patients
New patients are required to complete urine drug tests (UDTs), which can be performed in house or sent out if specific drug levels are required. Federally, marijuana is an illicit substance and is not prescribed or dispensed. Unpredictable effects of traditional medicine on the UDT have been observed. If a UDT shows positive for illicit substances, a discussion with the patient on toxicity and risks is initiated allowing them to choose to continue to use other substances for pain or use only the pain medication(s) appropriately prescribed by GIMC providers. Patients can be deemed ineligible for PMC management if they do not discontinue the use of illicit substances.
Health care providers and pharmacists involved in the prescribing or dispensing of controlled substances also complete a review of the patient’s PMP profile. It is mandatory in NM to complete PMP surveillance prior to prescribing controlled substances in quantities greater than 12 units within a 72-hour period and every 3 months for refills of chronic opioids.11 The PMP Interconnect service allows registered providers in NM to search for controlled substance usage in 25 states. All but 1 state in the U.S. has a PMP in development or in place. Federal providers who do not have a NM professional license also may apply for a NM PMP login to take advantage of the PMP Interconnect service. If the patient’s PMP is negative for prescribed opioids or positive for nonprescribed substances, the providers will conduct more research to reassess the risks and benefits of ongoing opioid therapy.
Random pill counts for tracked patients also have been incorporated into the PMC policy. These pill counts can be requested regardless of clinic appointment dates and can show whether patients are taking too many pills or diverting pills. Pill counts also may show that the patient may not need as many tablets per prescription if they consistently have more than expected based on dosing frequency. If a patient has adhered to prescribing recommendations, he or she may be allowed an early refill of the chronic opioid to cover them during a vacation or other unexpected event. However, if the pill counts are not consistent with instructions, then prescribing may be restricted to a 5-day, 7-day, or 14-day supply only. If patients do not present for pill count within 24 hours of the request, they can have their opioid use privileges at GIMC revoked as consented in the pain agreement. Patients are educated on proper storage and security of opioids medication at home and funding for lock boxes is expected in the near future. Patients may be referred to other services if opioid-use disorders are identified and confirmed.
Other administrative components of the pain management pharmacist responsibilities include clinical chart reviews before appointments or telephone consultations, sending appointment letters, contacting patients about and conducting random pill counts, and documenting PMC visit notes and updating flowsheets (eAppendices 4 and 5, available at www.fedprac.com). Currently under development is an EHR function that can quickly provide a summary of a patient’s pain management without a tedious search through the chart. Pain management pharmacists regularly instruct pharmacists and providers on changes in regulatory requirements of pain management as it pertains to prescription fills or clinical indications.
Ancillary Pharmacy Services
All pain patients on opioids therapies receive an annual pain evaluation. This evaluation provides a holistic description of the patient’s pain, a second opinion, and a collective review of the safety and efficacy of treatment. Components of the pain evaluation include review of medication toxicities and adverse effects, reconciliation of the treatment with current pain diagnosis and intensity, and coordination of opioid tapering schedules. Physical assessments and pill counts also are performed. Issues that have been uncovered include incidences of opioid-induced hyperalgesia and patients filling opioids prescriptions without taking the medications because they did not want to tell the provider the medication did not work.
Naloxone overdose prevention training and dispensing has been critical for ensuring maximum safety and life-saving methods in the realm of opioid therapy. Providers, patients, and rescue buddies are trained in the indication for, the administration of, and directions after naloxone use. Patients then are provided with naloxone nasal spray after the conclusion of the training and with instruction on refill procedures. Naloxone can be administered without legal penalty by anyone in NM. When refills for naloxone are requested, a naloxone-specific refill note is filed in the EHR to collect data on naloxone usage. In collaboration with a local suicide and substance abuse prevention network, 2 pain management pharmacists have created a Pills Can Kill booklet for dispersion to patients in waiting rooms, offices, schools, and throughout the county.
MedSafe receptacles (Houston, Texas) for collection of unused or unwanted medications, including controlled substances, are available in the pharmacy. These receptacles give patients a convenient and free outlet to remove circulating opioids from general access in the community.
