To get a clearer perspective on the medication management business, it helps to ask a pharmacy catering to the long term and post-acute care (LT/PAC) market to explain how it operates in what is an increasingly complex world where filling prescriptions is just the tip of the iceberg when it comes to the responsibilities of meeting the needs of modern skilled nursing centers.

When Provider asked T. J. Griffin, chief pharmacy officer for PharMerica, what they focus on when it comes to medication management, the first answer is “polypharmacy.” This, he says, is a broad term that means PharMerica works to make sure that during drug regime reviews all medications are being used appropriately for the diagnosis, and that all of the clinical work being performed, like lab tests, coincides with a patient’s condition and the drugs being used to treat it.

This process is also an opportunity to limit the side effects for a patient and consider alternative medications. “We ask if the drug causing other effects, and for which we have to prescribe more drugs to treat those side effects, may be replaced by a more appropriate drug, which could help us discontinue the other meds in the first place,” he says.

Does this type of medication management include antipsychotics? Griffin says yes, with antipsychotics all part of the list PharMerica uses to make sure they have the appropriate diagnosis and that product is appropriate for the patient.

In tackling the issue of antipsychotics in collaboration with their client providers, he says there has been a huge emphasis on educating everyone in the facility and within his own company on issues of appropriate use.

Push for Fewer Antipsychotics

The past decade has seen the movement to install procedures for gradual dose reductions, for instance, asking if patients, given their ages and specific conditions, really need to be on a high dose for a particular medication.

“This is a huge part of what a consultant pharmacist does, and the statistics bear out that PharMerica does a good job of that as we have seen a huge reduction in antipsychotics in the last five or six years,” Griffin says. He points to the growth in nonpharmacological interventions that have helped to stem the old-style “drugs first” mentality.

“Nonpharmacological programs like in the form of music therapy, which has gained real traction in the skilled nursing facility setting and memory care space. These interventions really work,” he says.

When asked if it is odd that a pharmacy works to curb the use of medications in some cases such as antipsychotics, Griffin says the role of PharMerica is not to sell drugs, but instead to make sure medications are used appropriately. “We are happy to make sure the medication load is as low as it can be and as appropriate as it can be,” he says.

What About Opioids?

Appropriate use of medications takes on a whole other level of importance in the case of opioids, with Griffin calling the drugs a “different ball game” that involves numerous methods to keep them limited to those patients who must have them. Facilities, he says, have undertaken their share of the load and are wrongly cited as sources of opioids diversion.

But as far as opioid management goes, he says of course a consultant pharmacist reviews the opioid load on a patient to ensure that their morphine equivalents (the standard measuring stick for dosage and potency) are not too high.

“In some ways opioids are just a normal part of medication management, but when it comes to the use of them, there are a lot more rules and regulations. For instance, you cannot use a chart order in a facility as a narcotic prescription,” Griffin says.

“So, we have to collect actual narcotic prescriptions from facilities, and that becomes a big challenge sometimes if the patient is admitted at 9:00 p.m. and you have to track down a doctor for a verbal emergency order for morphine or Oxycontin.”

The fact that tracking down a doctor can be a tricky exercise is why so many states are going to mandatory e-prescribing, which makes that whole process much easier, he says.

Not Just Here to Say No

To keep on top of the pervasive nature of opioids and their potential for abuse, Griffin says PharMerica does internal training once or twice a year to educate their pharmacists and pharmacy consultants on the latest developments with the Controlled Substance Act.

“You cannot work for us without the training, and we offer continuing education within facilities as well,” he says.

For those who talk about the possibility regulations have gone too far, Griffin says this is a legitimate question once so many pharmacies shut down in some of the higher-opioid-usage states. “You had retail pharmacists not wanting to fill controlled substances at all, so they would turn everybody away because they did not want the scrutiny of the DEA [Drug Enforcement Administration], and that is just not good care,” he says.

“If we have a question, then we call and ask a physician why they are prescribing an opioid to understand that it is for a legitimate medical use. That is our job as a pharmacist; it is not just to say no.”