The role of the pharmacist has morphed throughout history from a purveyor of household cleaners, alcoholic beverages, and medicinals, to dispenser of prescription drugs, to valued member of the health care team. The latter role continues to develop as evidenced by our growing recognition of our status as clinicians.
We must provide value as clinicians – more than just vaccinators and dispensers. Recent articles have highlighted a common misconception, likely fostered by the DEA, that pharmacists should be “gatekeepers” for the prescribing and dispensing of controlled substances. What is our role and how do we use Prescription Drug Monitoring Program (PDMP) data to fulfill that role?
The PDMP is there to assist in assessing the risk associated with the initiation (or continuation) of the intended drug therapy for the patient. It provides little to no context for the submitted records and certainly does not provide sufficient data, solely upon which a prescribing or dispensing decision should be made.
A great example is the use of multiple clinicians, even when geographically distant from one another. I have witnessed an elderly patient who was housed for several months with each of three daughters who did not even live in the same state. I have seen clinician changes due to death, retirement, sabbaticals, pain specialist referrals, and/or other causes, including insurance network changes. Most of these changes are not in the control of the patient.
Remember: the prescribing clinician has already determined the need for the drug therapy. That means, excepting diversionary activity or malpractice, the pharmacist’s job is not to determine the therapeutic need – we often don’t even know the diagnosis. No, our job is to assess the risk associated with that therapy and to implement risk-mitigation strategies to ensure maximum benefit with minimal risk.
Elevated risk should result in consultation with the relevant participants. This may be the patient/caregiver, the prescriber, and/or other pharmacists. Thereafter, a treatment plan should be developed and implemented with patient and potentially prescriber participation. Tactics can include limited quantities, no refills, random drug testing, a pain contract, the addition of alternative pain medicines (Rx or OTC), non-drug therapies, such as acupuncture, PT, OT, yoga, etc. and even caregiver control of the medication.
The PDMP data can provide great information that needs to be investigated before a clinical decision is made. Consultation with the patient, the patient caregiver, other pharmacists, and the clinicians themselves can easily elucidate the cause of many legitimate “red flags.” The primary problem I have seen with a “gatekeeper” mentality is the desire to have the system do the pharmacist job. Pharmacists often want the system to determine whether or not to dispense the drug. If that were really possible, what need have we for the pharmacist?
Systems are superior at analyzing and summarizing data but have no ability to contextualize it. PDMP data can’t and likely never will contain the supplemental information that might be the explanation for often legitimate therapies that invoked the “red flags” identified by the system.
Pharmacists using exclusively PDMP data to determine whether dispensing is justified are doing just half the job. Identifying potential patient risk via use of PDMP data is obviously the right thing to do. But not digging deeper into the “red flags” is often a shortcut to a clinical decision.
To all pharmacists in dispensing roles: do your job. Use the tools available to you, including PDMP data, analytical support, and consultation with the relevant partners (patients/caregivers, other pharmacists and clinicians) to assess the risk of the intended new or continued therapy and document your decision. And please, do not expect a computer program or even AI to make the clinical decisions you are paid and obligated to make yourself. I hope each of you uses your knowledge and abilities to enhance the safety, health, and comfort of your patients.
Michael is an expert on PDMP reporting as well as use of PDMP data in workflow. He has held positions with a major pharmacy chain, reporting to over 30 state PDMPs and with a major provider of PDMP data access. He has also been extensively involved with the development of PDMP reporting standards at both the National Council for Prescription Drug Plans (NCPDP) and the American Society for Automation in Pharmacy (ASAP). He is an advocate for judicious use of PDMP data to assist in assessing patient risk and is adamant that systematic analysis should initiate a conversation, not produce a clinical decision.
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