Prescribing, Dispensing Controlled Substances Focus of Consensus Document

AAFP, Others Form Coalition to Determine, Disseminate Best Practices

March 05, 2014 03:59 pm Chris Crawford

In February, the AAFP joined a coalition of health industry stakeholders in issuing a consensus statement(www.nabp.net) that outlines collaborative steps the groups will take to ensure the delivery of responsible and effective patient care when it comes to prescribing and dispensing controlled substances.

The agreement reached by the 13 participating organizations, which represent physicians, pharmacists, pharmacies, regulatory boards, wholesalers, manufacturers and government agencies, acknowledges the need to work collaboratively to address the prescription drug abuse epidemic in the United States and to help health care providers in various roles comply with their legal responsibilities for prescribing, dispensing and distributing controlled substances, according to a National Association of Boards of Pharmacy (NABP) news release(www.nabp.net).

"The Academy is very concerned about the growing problem of prescription abuse," said AAFP President Reid Blackwelder, M.D., of Kingsport, Tenn. "So we recognize that the best way to approach any serious issue is to get the appropriate people together to discuss steps toward a solution. We need to weigh the risks and benefits of the recommendations being made."

Story highlights
  • In February, the AAFP joined a diverse coalition of health industry stakeholders in issuing a consensus statement on prescribing and dispensing controlled substances.
  • Walgreen Co. and CVS pharmacies have taken steps to better regulate prescriptions for controlled substances.
  • As the health care delivery system seeks to enhance prescribing and dispensing practices, family physicians face several challenges as prescribers of these drugs.

Building Bridges

The consensus document was the result of stakeholder meetings convened by the NABP in October and December. The document, which was finalized at the December meeting, was developed by the following organizations:

  • American Academy of Family Physicians
  • AMA
  • American Osteopathic Association
  • Cardinal Health
  • CVS Caremark
  • Federation of State Medical Boards (observer)
  • NABP
  • National Association of Chain Drug Stores
  • National Community Pharmacists Association
  • Pharmaceutical Care Management Association
  • Pharmaceutical Research and Manufacturers of America
  • Rite Aid
  • Walgreen Co.

Following the October meeting, the AAFP drafted a document that, after approval by the Academy's Board chair, was submitted to the coalition members. In the document, the AAFP described the challenges facing family physicians who are grappling with this public health dilemma, which is fully laid out in the AAFP's official policy statement on pain management and opioid abuse.

Several of those challenges, the Academy noted in its missive to the coalition, are systemic, national issues. For example,

  • the transition to ICD-10 coding is underway and family physicians are actively engaged in ICD-10 education that will allow them to complete the transition by the Oct. 1 deadline;
  • the rollout of meaningful use stage two has made a real and immediate impact on practice and clinical processes for family physicians across the nation; and
  • many family physicians, in both independent and employed settings, are still trying to comply with Health Insurance Portability and Accountability Act guidelines and requirements.

In addition, said Amy Mullins, M.D., medical director of quality improvement for the AAFP, "family physicians are actively engaged in more practice-specific challenges, such as undertaking the transformation into patient-centered medical homes or participating in accountable care organizations" -- all while maintaining their focus on patients.

Root of the Problem

In June, Walgreen Co. entered into a settlement with the DEA(www.justice.gov), agreeing to pay a record $80 million for civil penalties under the Controlled Substances Act because of questionable narcotics-dispensing practices. For example, six Walgreens pharmacies ordered more than 1 million oxycodone pills in a single year compared with the industry average of 73,000 per year, according to the DEA. One Fort Meyers, Fla., pharmacy, in fact, went from ordering 95,800 oxycodone pills in 2009 to 2.2 million pills in 2011.

In addition, pharmacists dispensed prescriptions written by clinicians the Walgreens computers had flagged as problematic. This prompted the pharmacy chain to institute a "good faith" prescribing policy, which requires pharmacists to gather additional information when filling a controlled substance prescription, including diagnosis and expected length of therapy.

CVS has instituted a more focused approach to the problem. The pharmacy chain has identified the biggest narcotic prescribers nationally by comparing them with their peers in the same specialty and region, and then has attempted to contact the list of 42 identified outliers. After multiple attempts to contact prescribers by phone and letter, all but 10 were found to be legitimate. The remaining 10 will no longer have their prescriptions filled by CVS pharmacies.

Next Steps

With the intention of restoring and improving coordination among stakeholders, the 13 participating organizations will develop two subsequent consensus documents, according to the NABP release. The first document will identify "red flags" for both prescribers and pharmacists that will alert them of the need to review the legitimacy of a patient's presenting complaints, as well as the appropriateness of a controlled substance prescription.

The second document will outline the actions the stakeholder organizations will take to ensure these red flags are addressed in compliance with federal and state law and that prescribers and dispensers are supported in delivering the most appropriate patient care.

"The red flag document has real potential to help (prescribers) with the care of patients," Blackwelder said. "It sounds like the other document will be looking at guidelines to help improve communication (between physicians and pharmacists). Those two documents, for the interim, will have significant impact because they will open up lines of communication -- they will let anybody in that line of care have an opportunity to engage in a conversation about the guidelines to come."


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