Don't let the prescriber's hostility stop you from doing the right thing. As the pharmacist, you're the Rx expert.
Larry LaBenneIt was a busy Monday morning. I was focused on the many tasks at hand and trying to stay "afloat" when I heard a meek voice at the pickup window. "I hate to bother you, I know you are so busy, but I have a question.” I hope it’s not another cost/insurance-related question, I thought. Thankfully, it wasn’t.
“How long does it take for this medication to start working?” Finally, a drug related-question. She held out the bottle. The label said amitriptyline 100 mg at bedtime.
“How long have you been taking it?” I asked. “About three months,” she said. Assuming that she was using it for sleeplessness, I asked her whether she was sleeping any better at all since she started the medication. No, came the answer. Not at all. I felt a pang. Our pharmacy had already failed her; it was obvious that we had never followed up with her.
“The pain keeps me up almost all night," she said. Pain? “I had titanium wrist implants about two years ago, and the pain never really went away.” A cursory review of her profile showed gabapentin, duloxetine, and diclofenac. She had been extraordinarily compliant with the regimen, but had no understanding of its intended purpose. Another failure on our part.
“I feel so tired and confused, but I can't sleep through the pain,” she said. I took it as a plea for help.
I suspected that while attempting to treat the patient's chronic pain, the prescriber was intentionally avoiding the use of opiates. When I telephoned the physician's office, I discovered that the prescriber was a mid-level practitioner. In my experience, mid-levels are often less receptive than experienced physicians to pharmacist interventions.
My experience to date has been that mid-levels (with some exceptions) are less receptive than experienced physicians to pharmacist interventions. As I was sitting on hold, I was mentally bracing for the conversation; I had an idea how it was going to go. But I had promised this woman that I would do everything I could to help her, even if it meant a Monday-morning wrangle with the prescriber.
As expected, as soon the NP picked up the phone, the sarcasm began. “My receptionist tells me that you have a problem with what I prescribed. What makes you think that you know something about my patient that I don't?”
“I know that she is in chronic pain and is not getting relief from her current regimen,” I replied.
“You are not in a position to make that call,” he said.
The pharmacy is so busy right now, I thought. It would be so easy to just back down right now. I reminded myself that opportunities to help people are why I got into the profession to begin with.
“I could refute that point, but that isn’t why I’m calling,” I said. “This patient came to me with complaints of disorientation, sleep deprivation, and severe pain in spite of being heavily medicated, and I want to do something about it.”
“I don't prescribe opiates,” he quickly replied.
“So you admit that you’re placing a self-imposed principle above what may be the best option for your patient,” I said.
“That's not what I am saying.”
“Then what should I tell the woman at my counter who thought she could rely on you to properly mange her pain?”
“Okay, okay, okay,” he said with vexation. “The supervising physician is rarely on-site, and I don't feel comfortable managing patients who take opiates on my own, so I avoid prescribing them.”
“Maybe you should have established that several months ago, when you put your patient on a cocktail of medications that you knew were not right for her,” I said angrily.
Medical literature cites many well-known barriers to effective pain management, with concerns related to addiction, abuse, and diversion being among the foremost.
While most prescribers and pharmacists alike practice vigilance in combating drug diversion, there are many situations when even the most dutiful of practitioners provides inadequate care to patients with legitimate chronic pain issues because of anxiety about possibilities for addiction, abuse, and diversion.
Practitioners must practice equal vigilance in both the prevention of misuse and the identification and treatment of legitimate pain issues. However, as long as the measurement of pain remains generally subjective, and as long as drugs of abuse remain the treatment of choice for pain, identification of legitimate pain issues vs. drug-seeking behaviors will always be difficult.
A less-documented barrier to effective pain management is limited access to qualified pain-management providers. Pain is most often managed in the primary care setting, where access to physicians is often limited and consultations can be brief. The result is often generalized and ineffective pain management.
Effective pain management requires more than individualized treatment strategies; it also requires physicians to take the time to ascertain patients’ level of need for pain relief, as well as their cognitions, in order to assess whether pain medication is dosed to an analgesic level without dosing to euphoria. Both overdosing of opiates (to euphoria) and severe pain can result in impaired judgment and ability to communicate. Therefore, practitioners cannot safely assume that patients will always readily communicate their pain levels and/or treatment side-effects.
Perhaps the most important role that a pharmacist can assume for patients in chronic pain is to advocate for those whom we observe to have a clearly ineffective treatment plan.
By virtue of our accessibility, we regularly encounter circumstances in which patients complain of pain. In many of these instances, it is likely that a physician may simply be unaware that a patient finds the treatment plan ineffective. Such situations present an opportunity to show patients that we are more than good listeners; we can show patients and physicians alike that pharmacist intervention can make a difference.
As for the patient mentioned above, although I didn’t make any new friends at the practice, I think I earned the trust of the patient.
Incidentally, upon her referral to the local hospital-affiliated, outpatient pain-management clinic, a new care plan was quickly devised for her. Her situation made it very easy to determine the legitimacy of her pain issues, which also made the decision to advocate for her very easy.
Unfortunately, with many other patients, circumstances are not nearly so clear. Sometimes the best we can do is to act upon a hunch.
Larry LaBenne is staff pharmacist with Martin’s Pharmacy in DuBois, Penn. Contact him at firstname.lastname@example.org.