Real-time prescription monitoring provides some, but not all information in supplying Controlled Drugs and other high-risk medicines. Here’s how it can help.
It’s on the horizon – a state-based, nationally linked real-time prescription monitoring (RTPM) system.
For some, RTPM is new. In Victoria, for instance, it’s been here for a while.
RTPM provides some, but not all, information that can help pharmacists make more informed professional decisions to care for patients and help prevent misuse or dependency on potentially addictive prescription medicines.
But there is more to clinical judgments than the data RTPM provides, as PSA21 keynote speaker, Louisiana pharmacist Dan Schneider warns.
Pharmacists themselves not only have to be alert, he says. ‘You have to be persistent. You have to follow through and ask the questions and look at solutions and get involved.
Use RTPM, he urges, review it, ‘use it and enhance it’, is his message. After all, it is additional, verifiable information for use in combination with other data to make the best decision for patients. This includes information in clinical systems, My Health Record, patient-provided information and in collaboration with a prescriber. But doctors don’t always know better, says Mr Schneider, and systems are not always ideally set up.
For instance, in the United States, where ‘socialised medicine’ (universal coverage) is not overwhelmingly accepted and the opioid crisis has been raging for more than two decades, Mr Schneider says pharmacists at least now receive pre-authorisation from American health insurance companies to pay for certain opioid prescriptions, particularly in large quantities – similar to the PBS Authority system.
When red flags are thrown up by RTPM systems, Mr Schneider advises pharmacists to approach patients ‘with empathy and compassion. And you also have to talk to them and try to educate them’, he says.
Pharmacists, he says, ‘are there to make a difference’.
‘And when we don’t there are consequences. So don’t be afraid out there, Australian pharmacists, to stick your neck out and stand up … Don’t let money be the answer.’
So, how will next year’s expected national RTPM solution lead to meaningful interactions? AP asked pharmacists in two states already using RTPM to share a helpful experience.
Sam Flood MPS, Community pharmacist, Melbourne, Victoria – SafeScript
The majority of my interactions with RTPM have led to constructive conversations with people about their medicines use that has strengthened our professional relationship – most have been minor issues that haven’t led to any change in therapy.
One patient, who had a positive outcome from the use of RTPM, showed how easily a medicine can be used in a manner than affects life negatively, or doesn’t have the expected positive impacts.
This person had a few different conditions, and had several prescribers for those conditions, as the need arose. One day, the patient presented a prescription for paracetamol and codeine for an acute pain that was keeping them awake.
During the day, the patient felt so drowsy it was difficult to concentrate. When I dispensed the script, I noticed through the RTPM system that the patient had filled a prescription for diazepam three times in 3 months.
Asked about this, the patient mentioned that this was prescribed by a psychiatrist for panic attacks. When we dug into this a bit deeper, I realised the patient was taking it every day, rather than as needed.
We were able to discuss the role of diazepam for panic attack, and that taking it every day was the likely cause of the daytime drowsiness.
The RTPM system not only allowed me to see the medicine causing this problem, but also the frequency with which the prescription was filled, which (in turn) hinted at the misunderstanding about taking this medicine every day.
Adam Forrest MPS, Community pharmacist, Adelaide, South Australia – ScriptCheck SA
A patient presented a prescription on a Thursday for oxycodone IR 5 mg tablets, quantity 20. Her new GP instructed her to take 1 tablet every 4 hours when required.
During dispensing an alert flagged she had a history of drug-seeking behaviour dating back to 2014.
On review of her ScriptCheckSA history it was revealed a nearby pharmacy had also dispensed 10 tablets of oxycodone IR 5 mg earlier that same day, prescribed by a hospital doctor.
I chatted respectfully with the patient to explore the history further. I noted ScriptCheckSA had highlighted supply earlier the same day.
She explained she had visited the hospital emergency department after developing a severe, acute, painful skin reaction (which she willingly showed the pharmacy team) and received her first script of oxycodone with directions to take one to two tablets every 6 hours when required.
Realising it would not last long, and with a weekend looming, she had made a same-day appointment with her GP who prescribed 20 more tablets.
We explored her history of opioid misuse, she acknowledged the history but stated she no longer misused opioids and was determined to use the minimum amount required until her condition resolved. I telephoned the GP, who was aware of her misuse history, but unaware of the prescription from the hospital.
On review and discussion, the GP was satisfied the severity of the patient’s condition warranted the additional prescription, that she had successfully undergone opioid-dependency treatment in recent years, and the temporary use of opioids was unlikely to pose significant risks. The GP asked to see the patient after the weekend for review and follow-up.
He also thanked me for the information – and my help.
I counselled the patient on maximum doses, discussed other analgesics, (including recommending slow-release paracetamol to be used in addition to the oxycodone) and to later return any unused tablets to the pharmacy. She also thanked me for my support.
The use of ScriptCheckSA in that situation led to my collaboration with the GP and patient to better balance the benefits and risks of treatment with a drug with the potential for misuse. It also improved oversight of her acute pain management and reduced the risk of unsafe opioid use.
If I’m concerned about a red flag but can’t contact the doctor, should I withhold supply?
Possibly. A red flag requires the supplying pharmacist to take steps to improve patient safety. If you are unable to resolve a concern without contacting the patient’s prescriber, withholding all or part of the supply may be an appropriate way to do this.
Why am I seeing so many red flags?
Red flags identify high-risk situations – including the concurrent use of methadone and benzodiazepines. Red flag combinations generally require additional interventions, such as staged supply, witnessed dosing, at-home naloxone and/or additional medical oversight. Often these interventions are already in place. At other times, pharmacists need to take additional steps to protect patient safety.
Does a green flag mean it is safe to supply?
Not necessarily. For example, a prescription for a high-potency opioid (e.g. fentanyl patches) for a patient with no history of opioid use in a RTPM system would warrant further investigation for safety and forgery risk.
Can I flag a concern for a non-supplied prescription using the directions field in dispensing software?
No, this is not professionally appropriate and may create legal problems. Pharmacists should avoid use of subjective language or disclosure of sensitive information in dispensing instructions, including cancelled prescriptions for monitored medicines. Where medicines are not supplied, a cancelled prescription event is helpful in prompting other health professionals caring for the patient to take additional steps to inform patient safety.
If it is busy, can I check RTPM after the patient has left and follow up later?
RTPM systems are designed to inform safer prescribing and supply decisions of health professionals. In the supply of monitored medicines, this needs to occur at the point of supply. However, there may be times it is important to more closely review a patient’s record again after a supply event to support ongoing care of a patient.