April 30

Client Memories

I’m alone in my office right now and starting a delicious cup of coffee . . . it’s brewing. The smell of the coffee linked back memories of the many clients who were in my office, especially for the first time. Do you remember perhaps coming to the office in fear and anxious because you were facing the loss of your career and even incarceration? You were greeted by an always pleasant and well-mannered Gina who would have offered you a delicious, fresh brewed cup of coffee (always buy the best coffee for clients and myself) and she would remember exactly what you drank every time you came here.

I guess what I remember most is everybody would always tell Gina or my wife, Sylvia, RN that they feel so much more peaceful after seeing me. Some clients would come frequently just for the calming effect. I was always able to talk people into the right resourceful, frame of mind and then we would set about planning to make things better. Sometimes the client’s situation became incredibly better. Sylvia RN was here to remind me that nurses are always right and the Board wrong.

I miss all of you. Everybody was special and every case was unique. I never had the same case twice. My clients come from every country, know politics and history and science ─ epic stories from them. I can’t wait until people are back in the office and they have a really difficult problem to solve. Most professional baseball players can hit singles, but I’m addicted to crushing the long ball over the fence with runners on base. Ok, yes, I’ll take your money for the easy cases too that the guys on T.V. boast about, but it’s all fun.

My clients have problems in their lives that could bring financial and professional ruin if anybody even finds out about the problem. My best cases I can never talk about because you didn’t read about that doctor, nurse, psychotherapist or pharmacist in the newspaper! I wish I could tell you about the closed-door quiet stuff that nobody knows about but the client and me. New and old come back now.

February 3

Deadly Pharmacy Misfills at Chain Pharmacies

The January 31, 2020 New York Times published a lengthy and alarming news article entitled “How Chaos at Chain Pharmacies is Putting Patients at Risk”.

The Times wrote:

In letters to state regulatory boards and in interviews with The New York Times, many pharmacists at companies like CVS, Rite Aid and Walgreens described understaffed and chaotic workplaces where they said it had become difficult to perform their jobs safely, putting the public at risk of medication errors.

They struggle to fill prescriptions, give flu shots, tend the drive-through, answer phones, work the register, counsel patients and call doctors and insurance companies, they said—all the while racing to meet corporate performance metrics that they characterized as unreasonable and unsafe in an industry squeezed to do more with less.

“I am a danger to the public working for CVS,” one pharmacist wrote in an anonymous letter to the Texas State Board of Pharmacy in April.

“The amount of busywork we must do while verifying the prescriptions is absolutely dangerous,” another wrote to the Pennsylvania board in February.  “Mistakes are going to be made and the patients are going to be the ones suffering.”

https://nyti.ms/2Oiw42e

This will sound familiar to all of us who are pharmacists, but perhaps new to Times readers will be the “aggressive performance metrics at CVS and Walgreens”.

In Missouri dozens of pharmacists surveyed by their state board stated that the focus on metrics was a threat to patient safety and their own job security. “Metrics put unnecessary pressure on pharmacy staff to fill prescriptions as fast as possible, resulting in errors”. Of nearly 1,000 pharmacists who took the survey, 60 percent said they “agree” or “strongly agree” that they “feel pressured or intimidated to meet standards or metrics that may interfere with safe patient care”.

The Times article addresses real safety concerns for patient safety and hints at the stress and danger pharmacists are placed in. The article does not suggest any solutions.

My Related Thoughts

I hope that you have some new ideas to remedy the problems identified in The Times article because I would like to hear them. For what my opinion is worth, I suggest a number of areas to address, all of which are important:

  1. Outlaw performance metrics that reward pharmacists solely for filling more prescriptions per hour. The danger of this kind of metric is obvious.
  2. Reward pharmacists that practice safely.
  3. Chains should stop requiring pharmacists to sell customers immunizations, tests and procedures and refills. Using a Pharm D as a huckster to sell products takes time away from safely dispensing prescriptions. You cannot do two things at once.
  4. Abolish for the most part at-will employment of pharmacists. Instead, pharmacists should receive bonafide employment contracts for a reasonable term where pharmacists during the contract term can only be fired for good cause.
  5. Pharmacists at chain pharmacies have long needed real, bonafide aggressive union representation.
  6. A pharmacist union at chains is the only way to protect pharmacists from age discrimination—a huge problem for pharmacists.
  7. Employ safety engineers to make the pharmacy workplace safer for patients and safer and healthier for pharmacists.

Safety is not common sense, but is the subject matter of learned profession of human factors engineering. The goal is safe dispensing while minimizing harm to the bodies and minds of workers.

Advising Patients or Selling Products?

Some other thoughts I have are not directly related to reducing prescription error but, it is time to address these concerns as well. Chains should not use pharmacists to market vaccinations and health products. The reason chains have pharmacists implore patients to get vaccinated and refill their prescriptions is because pharmacists were among the most trusted professions in America. And a pharmacist endorsement used to mean something in terms of adding credibility to a product or service. The pharmacist is clearly more than busy just trying to accurately dispense prescriptions and advising prescribers on drug interactions and drug usage. Corporations should discontinue making pharmacists pester patients to buy products. Corporations should substitute real huckster “health professionals” such as Gwyneth Paltrow (women’s health), Jillian Michaels (nutrition products) and Dr. Oz (for everything else).

Pharmacists must safeguard their own profession from having its public image cheapened by merchandising. If we sell health products directly to the public in the same fashion as Gwyneth Paltrow and Kylie Jenner then it will be a very long trip back to regain the professions’ integrity with the public.

Decades ago, wise pharmacists tried to divorce the pharmacy from merchandising to elevate our status and utility but tragically their message was ignored and now lost. Business people see patients quite differently than health professionals do.

December 10

Truth About CDC Guideline

Authority figures are still intentionally disinforming health professionals about the recommendations in the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.

The cure for disinformation from authority figures is for health professionals to read the original source yourselves and interpret the meaning of sentences, paragraphs and phrases as you would any other important literature, and use dictionaries. Propagandists rely upon people being too lazy to read and think for themselves.

The following is yet another concise plea from the CDC exposing misapplications of its Guideline.  Read and share this widely.

CDC Advises Against Misapplication of the Guideline
for Prescribing Opioids for Chronic Pain

Some policies, practices attributed
to the Guideline are inconsistent with its recommendations

Media Statement

Embargoed Until: Wednesday, April
24, 2019, 5 PM, EDT
Contact: Media Relations
(404) 639-3286

In a new commentary external icon in the New England Journal of Medicine (NEJM),
authors of the 2016 CDC Guideline for Prescribing Opioids for Chronic
Pain
(Guideline) advise against
misapplication of the Guideline that can risk patient health and safety. 

CDC commends efforts by healthcare
providers and systems, quality improvement organizations, payers, and states to
improve opioid prescribing and reduce opioid misuse and overdose. However, some
policies and practices that cite the Guideline are inconsistent with, and go
beyond, its recommendations. In the NEJM commentary, the authors outline
examples of misapplication of the Guideline, and highlight advice from the
Guideline that is sometimes overlooked but is critical for safe and effective
implementation of the recommendations.

CDC is raising awareness about the
following issues that could put patients at risk:

  • Misapplication of recommendations to populations
    outside of the Guideline’s scope.

    The Guideline is intended for primary care clinicians treating chronic
    pain for patients 18 and older. Examples of misapplication include
    applying the Guideline to patients in active cancer treatment, patients
    experiencing acute sickle cell crises, or patients experiencing
    post-surgical pain.
  • Misapplication of the Guideline’s dosage recommendation
    that results in hard limits or “cutting off” opioids.
    The Guideline states, “When opioids are started,
    clinicians should prescribe the lowest effective dosage. Clinicians
    should… avoid increasing dosage to ≥90 MME/day or carefully justify
    a decision to titrate dosage to ≥90 MME/day.” The recommendation statement
    does not suggest discontinuation of opioids already prescribed at higher
    dosages.
  • The Guideline does not support abrupt tapering or
    sudden discontinuation of opioids

    These practices can result in severe opioid withdrawal symptoms including
    pain and psychological distress, and some patients might seek other
    sources of opioids. In addition, policies that mandate hard limits
    conflict with the Guideline’s emphasis on individualized assessment of the
    benefits and risks of opioids given the specific circumstances and unique
    needs of each patient.
  • Misapplication of the Guideline’s dosage recommendation
    to patients receiving or starting medication-assisted treatment for
    opioid use disorder.
    The
    Guideline’s recommendation about dosage applies to use of opioids in the
    management of chronic pain, not to the use of medication-assisted
    treatment for opioid use disorder. The Guideline strongly recommends
    offering medication-assisted treatment for patients with opioid use
    disorder.

The Guideline was developed to
ensure that primary care clinicians work with their patients to consider all
safe and effective treatment options for pain management. CDC encourages
clinicians to continue to use their clinical judgment, base treatment on what
they know about their patients, maximize use of safe and effective non-opioid
treatments, and consider the use of opioids only if their benefits are likely
to outweigh their risks.

The Guideline includes guidance on
management of opioids in patients already receiving them long-term at high
dosages, including advice to providers to:

  • maximize non-opioid treatment
  • empathetically review risks associated with continuing
    high-dose opioids
  • collaborate with patients who agree to taper their dose
  • if tapering, taper slowly enough to minimize withdrawal
    symptoms
  • individualize the pace of tapering
  • closely monitor and mitigate overdose risk for patients
    who continue to take high-dose opioids

Patients may encounter challenges
with availability and reimbursement for non-opioid treatments, including
nonpharmacologic therapies (e.g., physical therapy). Efforts to improve use of
opioids will be more effective and successful over time as effective non-opioid
treatments are more widely used and supported by payers.

CDC developed the Guideline to be
practical and created clinical tools to help primary care providers help
patients manage pain more effectively and safely, while mitigating the
potential risks of prescription opioids when needed. CDC has also created
specific resources on tapering, dosage, and appropriate application of the
Guideline such as:

CDC continues to help inform and
improve clinicians’ ability to offer safer, more effective care based on the
best available science.  As part of that process, CDC is evaluating the
adoption, use, and public health impact of the Guideline and its related
resources.

November 12

Good News We’ve Moved to a New Office Location

Christopher Pencak P.C. has moved to a location closer to many clients. Even if we aren’t closer to you the office is very close to I-94 saving you time. Our new office address is: Christopher Pencak P.C. , 37060 Garfield, Suite C-1, Clinton Township, MI 48036. Our phone number remains the same 586-598-4650 as does the fax number 586-598-4654.