Tools and Training to Optimize Pharmacist Decision-Making

The next presentation will examine common gray areas of community pharmacy practice. For example: under what circumstances do pharmacists fill early, transferred controlled substance prescriptions for out-of-town patients; when do pharmacists sell syringes to patients without proof of medical need; and how do pharmacists determine that a buprenorphine prescriber is acting in a patient\u27s best interest? These and other ethical or legal dilemmas challenge pharmacists as they try to balance identifying and preventing potential drug abuse and diversion with providing evidence-based, quality patient care. Based on data from pharmacists and pharmacy students, as well as established theory, presenters will describe typical approaches to decision-making. Multiple pharmacy cases will be discussed. Participants will learn how to integrate best-practice patient care systematically into common practice scenarios

Opioid-Prescribing Continuity and Risky Opioid Prescriptions

We aimed to better understand the association between opioid-prescribing continuity, risky prescribing patterns, and overdose risk. For this retrospective cohort study, we included patients with long-term opioid use, pulling data from Oregon\u27s Prescription Drug Monitoring Program (PDMP), vital records, and hospital discharge registry. A continuity of care index (COCI) score was calculated for each patient, and we defined metrics to describe risky prescribing and overdose. As prescribing continuity increased, likelihood of filling risky opioid prescriptions and overdose hospitalization decreased. Prescribing continuity is an important factor associated with opioid harms and can be calculated using administrative pharmacy data

Pharmacists\u27 Role in Opioid Safety: A Focus Group Investigation

Objective: The pharmacist’s role and responsibilities in addressing the opioid epidemic have yet to be clearly defined, particularly from the patient’s point of view. This qualitative study explores the pharmacist’s role in promoting opioid safety from the perspective of pharmacists and patients. Design: Focus groups. Setting: Patient groups were held in person, and pharmacist groups were held online. Subjects: Oregon pharmacists (N = 19, Mage = 39.0 years, range = 26–57 years, 58% female) and patients (N = 18, Mage = 60.1 years, range = 30–77 years, 71% female) with current experience dispensing or receiving opioid medications. Methods: Pharmacists were asked about the challenges and opportunities for opioid safety monitoring and prescription dispensing. Patients were asked about their experiences accessing care, medications, and safety information. Focus group data were analyzed by a multidisciplinary team using an immersion-crystallization approach. Results: Pharmacists and patients agreed that pharmacists are responsible for medication safety. Pharmacists expressed discomfort filling potentially high-risk opioid prescriptions and noted barriers such as lack of clinical information and discomfort policing high-risk prescribing. Patients were concerned about pharmacists potentially overstepping their professional responsibilities by interfering with prescribers’ clinical decisions. Conclusions: Feedback from both pharmacists and patient participants suggests that there is uncertainty in the degree to which pharmacists can and should confront the prescription opioid epidemic directly. Ambiguities in the pharmacist’s role may be best clarified through structured training promoting enhanced between-party communication

Use of Prescription Opioids Before and After an Operation for Chronic Pain (Lumbar Fusion Surgery)

Lumbar fusion surgery is usually prompted by chronic back pain, and many patients receive long-term preoperative opioid analgesics. Many expect surgery to eliminate the need for opioids. We sought to determine what fraction of long-term preoperative opioid users discontinue or reduce dosage postoperatively; what fraction of patients with little preoperative use initiate long-term use; and what predicts long-term postoperative use. This retrospective cohort study included 2491 adults undergoing lumbar fusion surgery for degenerative conditions, using Oregon\u27s prescription drug monitoring program to quantify opioid use before and after hospitalization. We defined long-term postoperative use as ≥ 4 prescriptions filled in the 7 months after hospitalization, with at least 3 occurring \u3e 30 days after hospitalization. Overall, 1045 patients received long-term opioids preoperatively, and 1094 postoperatively. Among long-term preoperative users, 77.1% continued long-term postoperative use, and 13.8 % had episodic use. Only 9.1 % discontinued or had short-term postoperative use. Among preoperative users, 34.4% received a lower dose postoperatively, but 44.8% received a higher long-term dose. Among patients with no preoperative opioids, 12.8 % became long-term users. In multivariable models, the strongest predictor of long-term postoperative use was cumulative preoperative opioid dose (odds ratio of 15.47 [ 95% confidence interval 8.53-28.06] in the highest quartile ) . Cumulative dose and number of opioid prescribers in the 30-day postoperative period were also associated with long-term use. Thus, lumbar fusion surgery infrequently eliminated long-term opioid use. Opioid-naive patients had a substantial risk of initiating long-term use. Patients should have realistic expectations regarding opioid use after lumbar fusion surgery

High-Risk Prescribing and Opioid Overdose: Prospects for Prescription Drug Monitoring Program Based Proactive Alerts

In order to develop a simple, valid model to identify patients at high risk for opioid overdose-related hospitalization and mortality Oregon PDMP, Vital Records, and Hospital Discharge data were linked to estimate two logistic models; A first model that included a broad range of risk factors from the literature and a second simplified model. ROC curves, sensitivity and specificity of the models were analyzed. Variables retained in the final model were age categories over 35, number of prescribers, number of pharmacies, and prescriptions for long acting opioids, benzodiazepines/sedatives, or carisoprodol. The ability of the model to discriminate between patients who did and did not overdose was reasonably good (AUC = .82, Nagelkerke R2 = .11). The positive predictive value of the model was low. Computationally simple models can identify high risk patients based on prescription history alone, but improvement of the predictive value of models may require information from outside the PDMP. Patient or prescription features that predict opioid overdose may differ from those that predict diversion

Association of Prescription Drug Monitoring Program Use with Opioid Prescribing and Health Outcomes: a Comparison of Program Users and Non-Users

Prescription drug monitoring programs (PDMPs) are a response to the prescription opioid epidemic, but their impacts on prescribing and health outcomes remain unclear, with conflicting reports. We sought to determine if prescriber use of Oregon\u27s prescription drug monitoring program (PDMP) led to fewer high-risk opioid prescriptions or overdose events. We conducted a retrospective cohort study from October, 2011 through October, 2014, using statewide PDMP data, hospitalization registry, and vital records.Early PDMP registrants (n=927) were matched with clinicians who never registered during the study period, using baseline prescribing metrics in a propensity score. Generalized estimating equations were used to examine prescribing trends following PDMP registration, using 2-month intervals. We found a statewide decline in measures of per capita opioid prescribing. However, compared with non-registrants, PDMP registrants did not subsequently have significantly fewer patients receiving high-dose prescriptions; overlapping opioid and benzodiazepine prescriptions, inappropriate prescriptions, prescriptions from multiple prescribers, or overdose events. At baseline, frequent PDMP users wrote fewer high-risk opioid prescriptions than infrequent users; this persisted during follow-up with few significant group differences in trend. Thus, although opioid prescribing declined statewide after implementing the PDMP, registrants did not demonstrate greater declines than non-registrants

Robin Hood: There Will Be Tights (A Medieval Drama Production)

Through the staging of this production, the English 312 (Medieval Drama) class developed an academic understanding of the original spirit of five Robin Hood plays & ballads and translated these in a lively manner into contemporary idiom for a modern audience. Students in this course have translated and staged ten very different productions since 1999, and this was our first attempt at popular folk theater. Robin Hood was a wildly popular figure during the late Middle Ages and the early Renaissance, and was often the May King in spring celebrations that combined mumming, music, dance, games, and action-packed improvisational theatrics; in our production, we tried to add some of that festive flavor in in between various scenes. These plays are slapstick and involve broad burlesque humor we might recognize from Monty Python or Benny Hill or modern British pantomime, and involve a certain level of audience participation; our actors performed in front, behind, to the side, and within the audience, and active spectator engagement was encouraged. During the Middle Ages, performances like these might include an opportunity to give alms to the poor, thus manifesting the type of generosity often attributed to Robin Hood. In our production, we invited charitable donations of cash, clothing, and non-perishable food stuffs for our local soup kitchen, and we gathered a substantial volume of such donations. Although we tend to think of Robin Hood as the Outlaw with a Heart of Gold who robs from the rich to give to the poor, this is a fairly late understanding of this figure; during the Middle Ages, on the other hand, Robin Hood provided a mischievous protagonist who inverted the power structure; our plays reflected this theme. In mythological terms, Robin is a Trickster: Like all Tricksters, he is impish and he inverts authority. Tricksters are also associated with fecundity and the rebirth of the natural world and growing season, and are sometimes androgynous. Thus Robin’s role as the May King underscores his identity as a Trickster. In our production, this ambiguity was manifested both by men in tights and by women cast as men: “Robin” is, after all, a gender-neutral name, and so we had two men and one woman playing Robin Hood. Indeed, the “Men in Tights” aspect of the Robin Hood tradition lends itself so readily to humor in our culture precisely because gender-bending and cross-dressing in slapstick comedy both reflects and subverts common perceptions and stereotypes regarding gender; the reason the Monty Python boys are so quick to put a lad in a skirt for a quick laugh is that such humor exposes in a non-threatening way basic tensions in our culture regarding gender roles. The humor in our play stemmed in part from exploiting such tensions