Below are suggestions pharmacies may want to include when developing their own best practices:
1. Demonstrate utilization of PDMP in a consistent and objective manner even if not in a mandatory required jurisdiction.
2. Show employment of educational material tailored to combating OUD (opioid use disorder). Encourage staff to document the provision of such material as well as the refusal of it.
3. Demonstrate continuing education for staff on opioid crisis etc. Topics may include fundamentals of addiction, treatment of opioid use disorder, and utilization of buprenorphine.
4. Empower pharmacists to question prescribing practices and address concerns to prescribing clinician or higher authority (e.g. boards of registration).
5. Consult with prescribing physician to verify prescription as well as validate clinical appropriateness.
6. Provide pharmacists with talking points when consulting with prescribers. For example: The 2016 Centers for Disease Control and Prevention prescribing guidelines encouraged non-opioid therapies for chronic pain and questioned daily dosages above 50 morphine milligram equivalents and advised avoidance of daily dosages of 90 MME or higher.
7. Be able to document that a review of patients’ current medications has been done in an effort to determine if other medications are interfering with pain management.
8. Consider including patient’s opioid status (opioid naïve or opioid tolerant). This can be utilized when reviewing orders for opioids and serving as a check for potential over medication.
9. Evaluate medication profile for concurrent opioid use.
10. Review patient history for allergies, obstructive sleep apnea, age, altered mental status, concomitant use of other sedating medications, opioid status, asthma or COPD, weight and renal function. These may impact tolerance to opioids.
11. Consider discussion with prescriber that the utilization of Long Acting (LA) opioids and doses greater than 40 mg be restricted to opioid tolerant patients and not used for acute pain management.
12. Consider segregating Morphine and Hydromorphone in the pharmacy storage.
13. Ensure patients utilizing opioids for chronic pain have access to naloxone.
14. Establish policies and procedures that focus on medication safety management to identify patients, providers and prescribers who may be inappropriately using or prescribing opioids.
15. The following are additional suggestions for the prevention of diversion of narcotics:
- Payment methods
- Early refills
- Out of area prescriptions
- Requiring identification of person picking up medications
- Process for ordering of opioids and the receiving of opioid deliveries are consistent with best practices
- Time delay on safe
- Disposal of medication for the community
16. Ensure that employees are knowledgeable regarding your Compliance Program and aware of how to access it.
1. http://www.pdmpassist.org/pdf/Reports_to_Dispensers_20190816.pdf Accessed 10/24/2019.
2. Botticelli M, Gottlieb M, Laderman M. EffectiveStrategies for Hospitals Responding to the Opioid Crisis. Boston: Institute for Healthcare Improvement and The Grayken Center for Addiction at Boston Medical Center; 2019.
3. CMS 2019 Medicare Part D Opioid Policies: Information for Pharmacists. https://www.pharmacist.com/sites/default/files/audience/CMSPartDOpioid%20Pharmacy%20Tip%20Sheet_20181206_508.pdf Accessed 11/25/2019
4. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain-United States, 2016. JAMA. 2016;315 (15):1624-1645. Doi:10.1001/jama.2016.1464
5. Pharmacy Today December 2017 Vol 23 Issue 12 Pages 40-41. Terri D’Arrigo.
6. Pennsylvania Hospital Engagement Network: Organization Assessment of Safe Opioid Practices. Patient Safety Authority An independent agency of the Commonwealth of Pennsylvania. 2014 http://patientsafety.pa.gov/pst/Documents/Opioids/organization.pdf
7. Philip W. Brummond, David F. Chen, William W. Churchill, John S. Clark, Kevin R. Dillon, Doina Dumitru, Lynn Eschenbacher, Toni Fera, Christopher R. Fortier, Kristine K. Gullickson, Kristen Jurakovich, Stan Kent, Jennifer Keonavong, Christine Marchese, Tricia Meyer, Lee B. Murdaugh, Richard K. Ogden, Brian C. O’Neal, Steve Rough, Rafael Saenz, Jacob S. Smith, ASHP Guidelines on Preventing Diversion of Controlled Substances, American Journal of Health-System Pharmacy, Volume 74, Issue 5, 1 March 2017, Pages 325–348, https://doi.org/10.2146/ajhp160919
8. Disposal of Unused Medicines; What You Should Know. U.S. Food & Drug Administration. https://www.fda.gov/drugs/safe-disposal-medicines/disposal-unused-medicines-what-you-should-know Accessed 12/5/2019