Interview with Steve Feldman, RPh, FASCP, President, American Society of Consultant Pharmacists
Feldman: My advice is not to accept that; pharmacists must do whatever they can-they should be "in the face" of the Medicaid decision makers, giving them evidence to substantiate the need for that particular medication. Pharmacists shouldn't sit back and surrender. Many states have a prior-approval process; if a pharmacist can make a good argument during this process, he or she might gain the approval of a restricted drug. Unfortunately, some are not willing to fight that battle.
I served on my state's Drug Utilization Review (DUR) Board for many years. If someone showed that a restriction was causing patient harm, the board certainly had to figure out how to deal with it, either by lifting the restriction or allowing a review process for people who really needed certain nonformulary medications. The same should be true for all state Medicaid agencies.
Unfortunately, we are hearing from our members about many problems with state Medicaid Preferred Drug Lists, especially with regard to their negative impact on seniors. The ASCP board of directors just approved a statement on this issue, which is available on the ASCP Web site (www.ascp.com).
This is a huge issue. It's one of many moral questions society needs to answer: Is Medicaid (which accounts for 70% of residents in nursing homes) a premium health insurance, or entitlement, that should allow people to get whatever they want? Or is it a way for those who can't afford healthcare to get what they need? We already can't afford Medicaid as we know it today. In the next 20 years, the system won't work; we need to change it. Ohio's Medicaid program and the projects in North Carolina could serve as models for some of that much-needed change.
Zinn: Has the consultant pharmacist's role evolved in the assisted living environment?
Feldman: Our role in that setting is really just beginning. Unfortunately, many long-term care pharmacy providers have serviced assisted living facilities as nursing homes and haven't understood the huge difference between them. This lack of understanding has created an environment of frustration for the assisted living industry. When I was a consultant pharmacist for Marriott's senior care division, one of my responsibilities was to create a model for how consultant pharmacists should operate in the assisted living setting, where the emphasis should be on wellness and risk reduction. It is not usually possible to conduct a traditional drug regimen review in that setting because of the lack of a comprehensive medical record. But a wellness/risk assessment can be done, and it is useful in that it will identify previously undetected or untreated diseases or medical problems and risks. The consultant pharmacist can work with the residents' physicians to reduce residents' risk factors. [For more information, see ASCP's Assisted Living Resource at www.ascp.com/public/pr/assisted.]
Zinn: Shifting to the clinical side of your role, what do you consider to be the most common medication error involving seniors that you encounter?
Feldman: The most common error in nursing homes is omitted doses; residents sometimes don't get the drugs that have been ordered for them. We know this by observing medication passes.
Another significant problem, and we're seeing it more and more, is the perception by physicians that medication doses should always be kept low in elderly patients. "Start low and go slow" is a good rule of thumb in this population; the trouble is, though, that some doctors' fear of giving too much medication prompts them to keep their patients at the initial low dose. They never titrate the dose upward to the efficacious dosage. For some medications that have no standard dose, doses have to be increased over time until the dose the patient needs is found. For example, low doses of cholinesterase inhibitors used for the treatment of Alzheimer's have no efficacy. But, because these agents all have a potential side effect of nausea, you have to start patients on a low dose for a few weeks before you can increase it to the amount they need to achieve a therapeutic benefit. Keeping patients at the starting dose, where the drug has no effect, is simply a waste of money. A similar problem is seen with the use of antidepressants in the elderly.
Zinn: What about pain management? Are physicians still withholding adequate doses of pain medications because they fear elderly patients will become addicted?
Feldman: Overall, I think we are aware that our history in nursing homes is to undertreat pain. The concern is really more related to central nervous system depression than addiction. Old people are very sensitive to narcotics; too high a dose can be very risky, so one must be cautious in prescribing pain medications for them. For example, regarding the transdermal patch used to deliver pain medication: The lowest-dose patch, which administers the dose over three days, delivers too large of a dose for some seniors with low body fat. So the smallest dose available can, in some patients, actually be an overdose. The risk is that pain medications can cause elderly individuals to fall and to appear totally tranquilized. So there are a lot of issues to consider when treating pain in the elderly.