#Kolodny: opiate tax is a good way to increase treatment and put money in his pocket ?

Posted on February 15, 2018 by Pharmaciststeve

Minnesota renews push for tax on prescription opioids

https://www.reuters.com/article/us-minnesota-opioid-tax/minnesota-renews-push-for-tax-on-prescription-opioids-idUSKCN1FY2VR

(Reuters) – Citing rising opioid fatalities, Minnesota Governor Mark Dayton on Wednesday announced a renewed legislative proposal to tax prescription opioid pills to help fund treatment.

 Minnesota is one of at least 13 states to have considered an opioid tax in recent years to help pay for the fallout from the United States’ opioid epidemic, although none have passed, according to the National Conference of State Legislatures.

Dayton’s proposal would levy a one-cent tax on drugmakers for each milligram of active ingredient in a prescription pain pill, generating an estimated $20 million a year for prevention, policing, emergency response and treatment.

Dayton last fall blamed “special corporate interests” for blocking a similar proposal in 2017.

“We must take decisive action in this legislative session to reduce abuses and to ensure that all Minnesotans suffering from these addictions receive the treatment and support they need,” Dayton, a Democrat, said in a statement.

The efforts come as a growing number of states and counties are suing opioid manufacturers to recoup costs of a worsening epidemic. In December, the U.S. Centers for Disease Control and Prevention reported that the U.S. rate of drug overdose deaths in 2016 grew 21 percent from the prior year.

 Minnesota had 395 opioid overdose deaths in 2016, an 18 percent increase over the previous year.

The Pharmaceutical Research and Manufacturers of America, a national trade association, said the proposal could divert money for developing new non-opioid painkillers and medication-assisted addiction treatments.

“It’s clear that this proposed tax ignores all the factors that led to this public health crisis, including the substantial influx of heroin, counterfeit fentanyl and other illegal drugs, and fails to recognize existing funding available for treatment, prevention and other important programs to help communities,” association spokesman Nick McGee said in a statement.

Dayton’s proposed measure, part of a larger effort to boost treatment, access to overdose medications and enforcement, will be debated in the legislative session starting Feb. 20.

 “I don’t see any reason why the taxpayers should have to pay to fix this. I believe (pharmaceutical companies) owe reparations,” State Senator Chris Eaton said Wednesday during a news conference, the Minneapolis Star Tribune reported.

Andrew Kolodny, an opioid policy researcher at Brandeis University, said the tax is a good way to increase treatment

“I don’t think we’re going to see overdose deaths start to come down until we do a better job of expanding access to effective outpatient treatment,” he said.

Filed under: General Problems | 3 Comments »

this is just one of so many bad reviews of optumRx

Posted on February 15, 2018 by Pharmaciststeve

this is just one of so many bad reviews of optum.

Original review: Jan. 22, 2018
I have been taking ** for chronic pain for 10 years plus. In 2017 we were covered with OptumRx and Blue Cross thru my wife’s employment at Walgreens. I am totally disabled and also on Medicare. For the year 2017 never had a problem getting my prescription filled. It’s now January 2018 and the trouble begins! My Doctor sent my prescription for ** to the pharmacy to be filled on January 17th within 2 hours of my requesting it. I am required to request refills 3 days before my medication is gone. Within an hour my pharmacy called to say they couldn’t fill the prescription because OptumRx needed a Prior Authorization. My pharmacy also sent a request to my Doctor’s office on my behalf. The pharmacy also recommended I call my Doctor as well just to expedite the Prior Authorization. On Tuesday I had enough medication to last until Friday morning the 20th.

On Wednesday morning the 18th I stopped by the pharmacy to get my prescription because the pharmacy said they should have approval by then. Well, no approval from Optum. I called the pharmacy again that afternoon and still no approval. I then called Optum to ask why my meds hadn’t been approved. I was told that they could take up to 7 days to approve the Prior Authorization. I told the rude customer service rep that the medication was an ** and I couldn’t wait 7 days for it or I would end up in the Hospital Emergency Room with severe withdrawals. I was then told that if it was an ** I would have to contact my Doctor and have another P.A. sent marked urgent and could then get my meds within 72 hours instead of 7 days and if that wasn’t soon enough I could pay for it out of pocket and would be reimbursed within 30 days.

I told her the cash price for a month’s supply of my medication is 900.00 dollars and I don’t have that kind of money available to me. Why is Optum doing this since it has never happened before. I then told her again without my meds I would be in withdrawals on Friday. I was told that this was the new policy due to the ** Crisis. First I asked her what has that got to do with me? This is a legal prescription written by my Doctor and I’m not an ** Crisis’ but I’m going to be if I don’t get my medication in time. I explained that I’m not allowed to get my prescription far enough ahead to cover the number of days Optum is requiring. No Doctor is going to do that nor would insurance pay for a next month’s refill that many days ahead. By this time I’m dumbfounded, angry and about to have a stroke. The Rep tells me that if I get that new P.A marked urgent it would more than likely be done by Saturday the 21st.

So by this time on Wednesday my Doctors office is closed. I was at my Doctors at 8am on Thursday to get the new Urgent P.A. sent. The new P.A. was sent within the hour. I waited all day Friday to hear from the pharmacy that I could come get my Prescription. Finally my Pharmacist called to say they still did not have approval. I call Optum again and was told that the approval Dept would be open Saturday and it should be done by then. I waited till 3pm Saturday and still no approval. Called Optum and told that they closed at 3pm and I was lucky that the Rep had even answered the phone but there was nothing they could do!

It is now 2:30 am on Monday and I’m in extreme pain and having horrible withdrawal symptoms. Fever, vomiting, diarrhea and just waiting for my Doctor’s office to open. Can’t go to the Emergency Room because Blue Cross won’t authorize the visit because I could have paid for the Medication but choose not to. I am so angry and hurting and just plain disappointed that OptumRx thinks what they’re doing is OK. If at all possible I will beg and borrow enough money to hire a Lawyer to stop OptumRx from continuing their horrible and damaging behavior! Please, Please don’t ever sign-up for coverage by these Monsters!

OptiumRX is part of UNITED HEALTH… and UNITED HEALTH is ENDORSED BY AARP..  I wonder how many millions of dollars that AARP gets from United Health for that endorsement.

Here is AARP’S MISSION STATEMENT FROM THEIR WEBSITE https://www.aarp.org/about-aarp/

Our Mission

AARP is a nonprofit, nonpartisan, social welfare organization with a membership of nearly 38 million that helps people turn their goals and dreams into real possibilities, strengthens communities and fights for the issues that matter most to families — such as health care, employment and income security, and protection from financial abuse.

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End the Epidemic – AMA

Posted on February 15, 2018 by Pharmaciststeve

Treatment Toolkit – February 2018

Treatment

The nation’s opioid overdose and death epidemic will not end without increased access to comprehensive, multidisciplinary care for pain, as well as enhanced access to high quality, evidence-based treatment for substance use disorders. Please use the tools below to add your voice in calling for increased treatment.

www.end-opioid-epidemic.org/digital-toolkit/treatment/

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DEA is emailing doctors recommendations on how to safely prescribe opioids.

Posted on February 14, 2018 by Pharmaciststeve

http://www.kristv.com/story/37509369/dea-advises-precautions-when-prescribing-opioid-medications

CORPUS CHRISTI – According to the CDC, more than 100 people die every day from an opioid overdose. The epidemic has been a nation-wide topic of conversation, but healthcare workers and the government are making efforts to lower the amount of opiate prescriptions. Some changes are already happening.

Doctors at the forefront of this epidemic have to make the tough decision of prescribing the pain medicine, or not.

But now, the Drug Enforcement Administration, or the DEA, which is in charge of fighting drug abuse in the country, is emailing doctors recommendations on how to safely prescribe opioids.

Dr. Justin Hensley, President of the Nueces County Medical Society, said until this week, he has never gotten a notice like this from the DEA.

When KRIS 6 asked why he believes the recommendations just came out, Dr. Hensley said, “Because there’s news about 60,000 people dying a year from them.”

The misuse and abuse of opioids can present a challenge for doctors to prescribe the appropriate medication to their patient. Dr. Hensley says regardless, doctors do what’s in their patients’ best interest.

“We don’t want to make people hurt,” Hensley said, “but we don’t want to make them addicted to pain medicine all of their lives.”

As a doctor, Hensley says he and his colleagues were always aware of the possible consequences linked to prescribing opioids. He believes it’s a positive sign the government has issued recommendations like this.

“Look at all this data, look at how drug companies are decreasing what they’re spending,” Dr. Hensley said. “Look at what the government is doing.”

The state of Texas also requires a special prescription to get schedule two medications, which include opioids like hydrocodone and oxycodone. Those prescriptions make it even more difficult to get ahold of schedule two drugs. The impact has already been seen at a Corpus Christi pharmacy.

Carlos Salinas, a pharmacist at Deleon’s Clinic Pharmacy, says within the last year, he’s seen a large decrease in the number of opioid prescriptions.

“The U.S. government along with other healthcare professionals are really, really trying to get control of the chronic opioid epidemic in our country.”

Texas has also provided recommendations on how to prescribe opioids. Those guidelines were enforced this month.

Filed under: General Problems | 9 Comments »

Minnesota governor proposes penny-a-pill fee on opioid prescriptions

Posted on February 14, 2018 by Pharmaciststeve

http://www.fox9.com/news/mn-penny-a-pill-opioids-fee

ST. PAUL, Minn. (KMSP) – Minnesota Gov. Mark Dayton is proposing a “penny-a-pill” paid for by drug companies to fund an opioid stewardship program for addiction prevention, treatment and recovery efforts in Minnesota. The governor estimates the program would raise $20 million each year.

Minnesota Department of Health data shows the state had 395 opioid deaths in 2016, an 18 percent increase over 2015. Of those 395 deaths, 194 were linked to prescription opioids.

CHANGING GUIDELINES: Last December, Minnesota announced new guidelines to change how physicians are writing prescriptions for painkillers. These new guidelines were the product of 18 months of planning by a group of physicians on both sides of the aisle. 

 Part of the opioid prescribing work group are two state lawmakers, Rep. Baker and Senator Chris Eaton, who both have lost children to opioid overdoses. Their goal is to curb the number of opioids being prescribed across the state. Statistics from the CDC show 47 opioid scripts are written for every 100 Minnesotans.

The new guidelines include:

1. Prescribing the lowest effective dose and duration of opioids when used for acute pain.  
2. Monitoring the patients closely, including prescribing opioids in multiples of seven days.
3. Avoid initiating chronic opioid therapy, make it so long term prescriptions would include face-to-face visits with the provider at least every three months. 

“To our patients already on these pain medications, we are not abandoning you,” said Dr. Chris Johnson leading the group.

Johnson emphasized the focus will be on educating and guiding physicians, patients and their families. Minnesota is currently the fifth lowest state in the country when it comes to prescribing opioids, but everyone involved in this effort points out doing better is vital. 

“One opioid prescription can start the downward spiral in the right person,” said Dr. Rahul Koranne, Chief Medical Officer for the Minnesota Hospital Association. 

LAWSUITS AGAINST DRUG COMPANIES: Multiple Minnesota counties have filed lawsuits against pharmaceutical companies, accusing the drugmakers of using an aggressive marketing campaign to change the culture of prescribing opioids. A lawsuit filed by Anoka County last month claims pharmaceutical companies convinced doctors that it was safe to prescribe opioids to treat not only severe and short-term pain, but also for less severe and longer-term pain, such as back pain and arthritis. 

“The defendants knew, however, that their opioid products were addictive, subject to abuse and not safe of efficacious for long-term use,” the lawsuit says. 

In 2016, the Food and Drug Administration recognized opioid abuse as a public health crisis. Despite this, the lawsuit says pharmaceutical companies have maintained that prescription opioids are not dangerous and have continued to sell the drugs. 

About 20 other Minnesota county attorneys filed similar lawsuits in November, led by Washington County Attorney Pete Orput. 

Only a BUREAUCRAT/POLITICIAN would believe that they could impose a “tax” on a business and/or their product and it will not be passed along to the final customer. The problem may be that pharmacy may end up taking the blunt of this new tax.. PBM (Prescription Benefit Managers) control what pharmacy gets paid… Pharma passes the cost to the wholesaler… wholesaler passes the cost to the pharmacy.. but.. the PBM refuses to reimburse the pharmacy for the additional cost.  Independents will probably get hit the worse, because the typical independent 95% of their revenue is from the Rx dept and the contracts that the pharmacy has with the PBM.. prohibits the pharmacy from collecting anything additional from the pt.. above what the PBM states is owed by the pt. Since >50% of independent pharmacies are located in towns <20,000… so those people living in rural Minnesota will get hit the hardest.  Losing maybe their only local pharmacy and the next closest pharmacy being miles away…  Since Minnesota is in “snow country” … how many pts may be forced to be out of their medication(s) for chronic conditions.. because of this whole fiasco ?

 

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As Opiate Rxs decline …DEA agents predicts increased OD’s

Posted on February 14, 2018 by Pharmaciststeve

Getting worse before it gets better: DEA agent predicts deepening opioid epidemic

TEMPE – The opioid crisis in Arizona is likely to grow, a DEA agent warned Wednesday, adding that it’s time to stop playing the blame game.

“For right now, unfortunately, it looks like the problem is getting worse before it gets better,” said Doug Coleman, a special agent for the Drug Enforcement Administration in Phoenix.

Coleman framed the war on opioids as a series of front-line battles that have not yet reached peak casualties.

He was among the law-enforcement and health-care officials who met at the second annual Arizona Opioid Summit to discuss solutions to an epidemic that has led to nearly 900 deaths and 5,810 drug-related overdoses in the state since mid-June, according to state health officials.

Last month, Gov. Doug Ducey signed the Opioid Epidemic Act into law. The measure provides $10 million in treatment for underinsured or uninsured patients, restricts the number of opioids that can be prescribed at one time and protects people from drug-related prosecution if they call for emergency help during a drug overdose.

In his presentation, Coleman praised the new law, saying Arizona is “forward thinking” and “a leader” in the national opioid crisis, which claims an estimated 115 lives every day, according to the National Centers for Disease Control and Prevention.

Doug Coleman, a DEA special agent, said everyone wants someone to blame for the opioid crisis — whether doctors or the drug industry — but that’s a waste of time and effort. He spoke Wednesday to law-enforcement and health-care workers at the second annual Arizona Opioid Summit in Tempe. (Photo by Fortesa Latifi/Cronkite News)

But the connections that led to the epidemic are intertwined and deep, he said, meaning there’s no magic medicine to cure the crisis.

Everyone is trying to figure out who to blame, he said, adding that the true answer is everyone is to blame: Doctors, pharmacists, patients.

“We have to get past the idea of who’s to blame because there’s not one entity that’s to blame,” he said. “We all, as citizens of the United States, demanded these products to ease our pain, and that’s what led to this.”

First, he said, patients demanded opioids to combat their pain. Then, doctors started prescribing more painkillers. In turn, pharmaceutical companies manufactured more drugs. They provided the building blocks for a tragedy.

“We have to stop blaming each other,” Coleman said. “We have to figure out a solution.”

Janice Morrison agrees. Her son, Brett, battled heroin addiction after he was prescribed opioids following a snowboarding accident. She shares Coleman’s concern that the Arizona opioid crisis hasn’t hit its peak.

“Because of shame and stigma and fear of prosecution, people don’t reach out for help,” Morrison said. “It’s just a big mess.”

Morrison thinks law enforcement and government officials need to work with people who have experienced addiction in order to reach solutions.

Most of the conference at the Tempe Mission Palms Hotel centered on sessions to discuss law-enforcement work, pain management and treatment options.

In other ways, it was similar to other industry conferences, with a lobby of vendors offering free pens, candy and other giveaways. A rehab center marketed treatment options, such as $11,000 for a six-week outpatient program and $65,000 for a six-week inpatient program.

As this chart shows, the number of opiate Rxs in 2016 was slightly less than in 2006, but the red line indicates the number of overdose deaths. Of course, the way that the CDC collects data in this OD chart is all drug overdose deaths or just opiate OD deaths. We also don’t know how many of the drug OD deaths are in fact SUICIDES.

Why does the chart start in 2006, when many blame Purdue Pharma for the opiate crisis when they introduced it in 1995. Shouldn’t the chart cover the entire time frame that seemingly everyone is blaming ?

As for the old saying goes, figures never lie and liars always figure

Filed under: General Problems | 5 Comments »

Judge Says DEA, Not Courts, May Be Better Forum to Challenge Cannabis Policy

Posted on February 14, 2018 by Pharmaciststeve

https://www.law.com/newyorklawjournal/sites/newyorklawjournal/2018/02/14/judge-says-dea-not-courts-may-be-better-forum-to-challenge-cannabis-policy/

A federal judge on Wednesday lobbed tough questions at an attorney for a group of plaintiffs challenging the constitutionality of marijuana prohibition, asking why his court is the best forum to push the government to cease enforcement.

But U.S. District Judge Alvin Hellerstein of the Southern District of New York, while hearing oral arguments on the government’s motion to dismiss the suit,

challenged the Drug Enforcement Administration’s position that marijuana has no acceptable medical use.

“It may not be universal, but some states in their legislative findings have found that there is a legitimate medical use,” Hellerstein said during an exchange with a federal prosecutor before a standing-room-only courtroom.

“So you can’t say what you’re arguing. The argument doesn’t hold.”

The plaintiffs in the suit, filed in July, are challenging the classification of marijuana under the Controlled Substances Act as a Schedule I drug, which is defined as drugs with a high potential for abuse, no accepted medical use, and no way of using or testing them safely, even under medical supervision.

Other Schedule I drugs include heroin, LSD and ecstasy. The plaintiffs ask for a permanent injunction to prevent enforcing cannabis under the CSA.

The lawsuit was filed on behalf of a diverse assortment of plaintiffs, including Marvin Washington, a former professional football player who now works in the cannabis industry; Alexis Bortell, a 12-year-old girl who suffers from epilepsy and says cannabis has kept her seizure-free for more than two years; and Jose Belen, an Iraq war veteran who uses cannabis to treat symptoms of post-traumatic stress disorder.

The plaintiffs argue that the Schedule I classification for marijuana violates their due process rights, First Amendment protections and the right to travel. The oral argument in their case comes as 30 states and the District of Columbia have adopted laws legalizing marijuana, but after U.S. Attorney General Jeff Sessions announced he would roll back the Obama administration’s hands-off approach to states that legalized marijuana.

In arguing for dismissal of the suit in the Southern District, the government contends that changing marijuana’s classification of a Schedule I drug needs to be accomplished through administrative rule-making.

Assistant U.S. Attorney Samuel Dolinger of the Southern District U.S. Attorney’s Office, who presented oral arguments on the government’s behalf, said the plaintiffs have yet to exhaust their administrative remedies to reclassify marijuana under the CSA.

“A ruling on exhaustion would dispose of all of the claims in this case,” Dolinger said. But the plaintiffs argue that, in passing the CSA, Congress created a “completely dysfunctional” construct in which a drug can only be rescheduled through testing but has classified marijuana as so dangerous that it could never have a conceivable benefit.

Additionally, the plaintiffs contend, waiting for the DEA to rule on petitions to reclassify cannabis is often a lengthy process, noting in their court papers that a petition to transfer cannabis to any other classification and another to transfer it to a Schedule II drug, filed in 2009 and 2011, respectively, did not receive rulings until July 2016. Both were denied.

“I represent people who need cannabis to live,” said Michael Hiller, one of the plaintiffs attorneys, during oral arguments.

But Hellerstein, who was appointed to the bench by President Bill Clinton, told Hiller a district court is not the proper place to “weigh all the conflicting elements” of how the DEA determines its narcotics schedule, which he said includes assessments of a drug’s danger to the community.

“An agency is set up to weigh all the things you want me to do,” Hellerstein said. “I think the right thing to do is defer to the agency,” Hellerstein said.

Hellerstein reserved judgment on the government’s motion, telling Hiller his side presented “provocative arguments.”

In addition to Hiller, the plaintiffs are represented by Hiller PC attorneys Lauren Rudik and Fatima Afia; David Holland of the Law Offices of David Clifford Holland; and Joseph Bondy of the Law Offices of Joseph A. Bondy.

Dolinger was joined in the courtroom by Assistant U.S. Attorney David Jones.

The plaintiffs have faced uphill battle so far. In September, Hellerstein denied the plaintiffs’ request for a temporary restraining order to cease cannabis enforcement under the CSA.

Additionally, the U.S. Court of Appeals for the Second Circuit previously held that the Schedule I classification for cannabis is constitutional and, in a 2016 ruling, U.S. District Judge Elizabeth Wolford of the Western District of New York ruled in a criminal case to reject a constitutional challenge to the Schedule I classification.

 

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‘She Trusted Me, and I’d Turned Her Away’

Posted on February 14, 2018 by Pharmaciststeve

Physician wracked with guilt after losing patient to overdose

https://www.medpagetoday.com/blogs/themethodsman/71172

Audrey Provenzano, MD, MPH, a primary care physician in Chelsea, Mass., avoided getting the waiver needed to prescribe buprenorphine (Suboxone), and so was unable to treat an opioid-addicted patient who subsequently died of an overdose. She wrote about this experience in a moving piece appearing Wednesday in the New England Journal of Medicine.

We discussed that story, medicine’s stormy history with opioid abuse, and the politics of the buprenorphine “waiver” in a Doc-to-Doc video conversation.

Filed under: General Problems | 1 Comment »

CVS’s Transparent Opioid PR Stunt

Posted on February 14, 2018 by Pharmaciststeve

https://www.acsh.org/news/2017/09/28/cvss-transparent-opioid-pr-stunt-11880

CVS has taken it upon itself to enact rules that allow their pharmacists to ignore a physician’s prescription by changing the number of pills, the daily maximum dose, and even the form of the drug itself. And the company’s new policy is based on a decidedly faulty premise, which I will describe below. What the company just did is bad news for both physicians and their patients. Let’s try to set them straight.

Since I am nothing if not helpful, I have taken the liberty of writing up a memo for the company to distribute to its pharmacists. Of course, CVS is free to tinker with the phraseology if they so choose. Corporate-speak is not one of my strengths. Here it is:

MEMO TO ALL CVS MANAGERS (RE: DISPENSING PRESCRIBED PAIN DRUGS, NEW PROTOCOL)

  1. In the morning, open the store.
  2. Have your pharmacists go behind the counter and do their jobs.
  3. Not the jobs of the FDA, DEA, CDC or the KGB.
  4. Tell them to dispense the pills that the doctor ordered. It is the doctor’s call, not theirs.
  5. Close the store.

I see CVS’ recent move to place restrictions on pain medication as little but a calculated attempt to look like heroes in a crisis. This just doesn’t smell right. It is clearly self-serving. And pardon me if I’m not impressed by the company’s $2 million contributed to opioid abuse treatment charities. It may appear to be altruistic, but it’s peanuts to CVS since it represents a whopping 0.02% of their annual profits and 0.001% of its sales ($177 billion in 2016).

I can almost picture all the CVS executives on the golf course patting themselves on the back for scoring big PR points with the public. Perhaps a few of them are even delusional or uninformed enough actually to believe that they just did something useful. But I doubt it. This has “disingenuous” written all over it.

And, if I’m a doctor, I’m gonna be mighty unhappy if a pharmacy doesn’t do what I tell them (not ask them) to do. Plenty of doctors around the country are not terribly happy about it either. I spoke with six. 

One is Dr. Arthur Kennish, a New York cardiologist who has been hassled, just like many other physicians for having the unmitigated gall to treat patients the way they choose. 

“CVS has some nerve. The use of opioids, or any other drug, really, is up to the doctor and his or her patients, not a pharmacist. This is a terrible precedent, which will drive an even bigger wedge between physicians and patients. It’s already too big” – Arthur Kennish, M.D. September 26, 2017

And Dr. Thomas Kline, who is a geriatric specialist in North Carolina, and active in fighting what he calls “a war on pain patients” was even blunter:

“Limiting prescriptions discriminates against 9 million people with painful diseases who will never addict nonetheless suffering inconvenience and humiliation to assuage the comfort zones of a long history of abstinence reformers, coming once again to the polemic footlights.” – Thomas Kline, M.D. September 27, 2017

(See below for quotes from Council M.D.s on this matter)

Here is the breakdown of what CVS is doing that has pain patents terrified and doctors angry. 

  1. Limiting to seven days the supply of opioids dispensed for certain acute prescriptions.

Let’s say that an orthopedic surgeon knows that an operation will cause a patient two weeks of bad pain, at which point they can switch to something like Advil. Executives decided that the store will only give a new patient a one-week supply. Do they know better than the surgeon what is best for his patient? 

     2. Limiting the daily dosage of opioids dispensed based on the strength of the opioid.

At least in the first case, despite wasting the doctor’s time by making him write another script, and having to make two trips to the pharmacy instead of one, at least the patient will get what is needed. But having a retailer dictating a maximum daily dose is really crossing a line. CVS is not qualified to make this determination. Scientifically, it’s even worse. All people react differently to opioids. For example, some are 15-times better at metabolizing the drug than others. So an arbitrary maximum dose may work well for one person but be inadequate for another. Do pharmacists know these patients better than the physician? Do CVS executives even know this?

     3. Requiring the use of immediate-release formulations of opioids before extended-release opioids are dispensed.

  • This is really dumb. Depending on an individual situation, there can be advantages for either immediate-release pills or time-release. A regular opioid pill will bring faster relief than an extended-release version, but wears off much sooner. Time-release medications result in a more consistent concentration of the drug in the blood; fewer ups and downs, as illustrated in Figure 1 below, but they don’t dull the pain as quickly. How exactly has CVS figured out that short-acting opioids are better than long-acting ones for new patients? 

 

Figure 1. A comparison of blood levels of short-and-long acting pain medication.

The CVS policy also raises larger and more far-reaching concerns. Who is in charge of our health? Why are laws being made that tell us how much medicine we can take much less corporate guidelines? Since when do pharmacists at retailers overrule physician decisions?

Unless there is an obvious prescribing error or a serious drug-drug interaction or any other pharmacological issue, they can’t (1). Until now. And you don’t want them to. It takes away a little more of your control of your own health, something that has been trickling away for years.

Why is CVS doing this now? I’ll speculate. During a crisis, it is always a good idea to hop on the “Let’s find someone to blame” bandwagon. Doctors and drug companies have taken the brunt of the blame (and the FDA to a lesser extent) because they are easy and convenient targets. Yes there were some unscrupulous doctors who ran “pill mills” and did much damage. And Purdue Pharma, the makers of OxyContin, got a $685 million spanking for promoting an exaggerated safety profile of the drug. There are other companies that don’t look so hot right now either. But blame is merely a distraction from the problem at hand. Hundreds of people are dying every day and it’s not from the pills. There’s your crisis.

It is always easier to run with the crowd than swim against it, no matter which way it’s going. It did not take long for politicians to buy a one-way ticket in the wrong direction: ‘Sure, everyone knows that these damn pills are killing everyone, so let’s stop them,’ is basically what they tell the public.  In what almost seems to be a tough guy contest, states are blindly following the CDC’s 2016 very flawed “advice” and passing some awful laws. If Kentucky enacts tough laws, then Florida better get tougher, as evidenced by Gov. Rick Scott’s proposed law that would allow a three-day maximum prescription unless strict conditions are met. What’s next? Mandatory bamboo under the fingernails tolerance workshops? If there’s a problem someone has to do something about it, right? If it’s the wrong thing, what are you gonna do? At least it sounded good.

But, perhaps the worst problem with these already-flawed policies and laws is that they are based on the premise that pain patients got hooked on drugs and are now dying from fentanyl. This is demonstrably false. There is ample evidence in the literature that very few pain patients become addicts; estimates range from .05-10%. (See: Heads In The Sand — The Real Cause Of Today’s Opioid Deaths.“) So the ill-conceived laws that are popping up like weeds and policies that CVS initiated are solving the wrong problem. In (supposedly) trying to protect pain patients from themselves, these policies do nothing but punish them with pain, terror, and despair while at the same time tying the hands of physicians who prescribed opioids wisely and responsibly. 

If CVS doesn’t know all of this, they should. If CVS does know this as well and doesn’t much care, you have to give them some credit. Nicely played.

Notes:

(1) In these cases, the pharmacist will consult the physician and offer advice if necessary. They are not overruling anyone. 

(2) Comments from American Council on Science and Health physicians:

“I have an OB/Gyn colleague who prescribed antidepressants to her patient. The pharmacist refused to fill it saying not within the scope of her practice. The pharmacist’s role is not to be questioning a physician’s clinical skill or clinical decision-making. Leave doctoring to doctors.” Dr. Lila Abassi

“Pharmacists, as part of their licensure responsibility, should check prescriptions for accuracy in dosage and can question the use of medications especially in settings of allergies or cross-reactivity with other medications on a patient’s med list. I do not believe that a pharmacist can or should refuse to fill a prescription based on quantities to be dispensed without speaking directly to the prescribing physician.” Dr. Charles Dinerstein

“For pharmacists to be able to override a physician’s order, given the limited scope of their training and that they are not privy to a patient’s entire clinical picture (or medical history), could put a patient at greater risk. As is current practice, discussions with the treating physician to clarify concerns are always welcomed and encouraged before a pharmacist fills a prescription. But, not mandates–and one not in the best interest of the patient is simply unacceptable.”  Dr. Jamie Wells

 

Filed under: General Problems | 4 Comments »

Discussing Benefits of Palliative Care

Posted on February 14, 2018 by Pharmaciststeve

https://www.practicalpainmanagement.com/resources/hospice/discussing-benefits-palliative-care

A recent meta-analysis found that palliative care interventions were associated with statistically and clinically significant improvements in patient quality of life (QoL) and symptom burden.1

Palliative care improves the quality of life of seriously ill patients.The study analyzed 43 randomized clinical trials, including data on 12,731 patients, with 35 of those trials using “usual care” as the control. While the associations with QoL and symptom burden were challenged by the heterogeneity of current research trials concerning palliative care,2 researchers found palliative care consistently associated with patient and caregiver satisfaction, as well as lower health care utilization.

“We’ve seen people who get involved with palliative care sooner definitely have a better quality of life, and they may live longer,” said Mary Lynn McPherson, PharmD, MA, BCPS, CPE, professor and executive director for advanced postgraduate education in palliative care for the University of Maryland’s School of Pharmacy in Baltimore, Maryland. The meta-analysis only included 1 study that had patient survival as a primary end point. In that study, Bakitas et al did find patient survival 1 year after palliative enrollment was better compared to patients who enrolled 3 months later.3

A similar study in 2010 found patients receiving early palliative care for their lung cancer showed better QoL and mood. And while patients who had “early” palliative care did receive less aggressive care at the end of life, their survival was still longer compared to patients who had standard care.4

Because palliative care is not concerned with patient survival, clinicians and patients may hold the negative perception that patients receiving palliative care will not live as long, something the data appears to disprove. Palliative care “is an added layer along with everything else,” said Dr. McPherson.  “We’re turning the tide from getting practitioners to stop thinking palliative or hospice care means ‘giving up.’ Even hospice care doesn’t mean we’re giving up,” she noted. “There may not be hope for a cure, but there is still hope that we can relieve the symptoms, relieve existential angst, and so on.

“But palliative care is not always about terminally ill patients. It’s all about quality of life—maximizing quality of life and maximizing outcomes, whether they be clinical or terministic,” she concluded.

 

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