A New Age for Tramadol

Big news has once again hit the world of pharmacy recently: Tramadol is now scheduled as a schedule IV controlled substance in all states according to the Drug Enforcement Agency (DEA).1 On July 2, 2014 the DEA announced this update in the Federal Register.2 Tramadol and any product containing the substance will require a “C-IV” notification on all its labels as of August 18, 2014.1 Schedule IV is “defined as drugs with a low potential for abuse and low risk of dependence” according to the DEA.3

In 1995, tramadol was approved as an opioid analgesic with monoamine reuptake inhibition used for the treatment of moderate to severe pain in adults.2 A typical dose of tramadol is one to two tablets (comes as 50 or 100 mg tablets) every four to six hours as needed for pain, with a maximum dose of 400 mg/day.2 Withdrawal symptoms, tolerance, dependence, and addiction to tramadol have all been reported before.2 Since tramadol is an opioid, immediately we would be concern with abuse or misuse. Tramadol is most often abused in these specific populations of narcotic addicts, chronic pain patients, and health professionals.2 According to the DEA, a report by IMS Health National Prescription Audit Plus, tramadol was dispensed 43.8 million times in the United States in just the year 2013.2 American Association of Poison Control Centers reported 13,067 contacts with tramadol with 6,589 contacts being single substance exposures, and nine reported deaths in 2012.2 Another report completed in 2012 by the National Survey on Drug Use and Health stated “3.2 million people in the U.S. aged 12 or older used tramadol for nonmedical purposes in their lifetime.”2

While several states had previously scheduled tramadol as a controlled substance1, Missouri has no state law scheduling tramadol as a controlled substance. Therefore, Missouri pharmacists need to know and take action on several things in order to be compliant with the August 18, 2014 effective date. Some of these actions required include:

  • All pharmacies and providers stocking tramadol or products containing tramadol must take inventory on or before August 18, 2014 and these substances must remain a part of all controlled substances inventories. 1, 4
  • All prescriptions for tramadol and products containing tramadol must follow the federal and state controlled substance prescription rules and regulations starting on August 18, 2014.1
  • Tramadol and products containing tramadol shall be marked as Schedule IV Controlled Substance in the pharmacy’s computer.
  • All prescriptions for tramadol must be changed over to reflect the specific pharmacy’s controlled numbering format for filing and record purposes.4
  • No electronic prescriptions shall be accepted for products containing tramadol, unless the pharmacy follows specific requirements in 21 C.F.R. §1311 set by the DEA.4
  • All prescriptions written for tramadol and products containing tramadol may only be refilled five times within a six month time period.4
  • All prescriptions written for tramadol and products containing tramadol will only be valid for 6 months.4
  • All prescriptions written for tramadol and products containing tramadol can only be transferred between pharmacies once.4 If pharmacies share an electronically, online, real-time database, then they may transfer the prescription as many times as allowed by the number of refills or expiration date.5

Some of these changes will cause confusion for patients and pharmacists will need to make sure their patients understand these changes in order to prevent misunderstandings in the future. For example, a prescription written for tramadol used to be valid for 12 months, with no restriction on the number of refills, and it could be transferred between pharmacies as many times as necessary.5 If you have any questions regarding the rescheduling of tramadol and products containing tramadol, contact the Missouri Board of Pharmacy. Overall, the addition of tramadol to a schedule IV will help prevent abuse and misuse, which will further protect our patients.

Ashley Buehler

UMKC School of Pharmacy at MU

PharmD Candidate 2015

MPA Rotation Student, July 2014


1DEA classifies tramadol a controlled substance. (2014, July 9). Retrieved from http://www.nabp.net/news/dea-classifies-tramadol-a-controlled-substance

2Tramadol (trade names: ultram®, ultracet®). (2014, July). Retrieved from http://www.deadiversion.usdoj.gov/drug_chem_info/tramadol.pdf

3Drug scheduling. (n.d.). Retrieved from http://www.justice.gov/dea/druginfo/ds.shtml

4Pharmacist’s manual an informational outline of the controlled substances act. (2010). Retrieved from http://www.deadiversion.usdoj.gov/pubs/manuals/pharm2/pharm_manual.pdf

5Rules of department of insurance, financial institutions and professional registration. (n.d.). Retrieved from http://www.sos.mo.gov/adrules/csr/current/20csr/20c2220-2.pdf

A Second Chance for Inhaled Insulin

Every pharmacy student has been told during their education that this profession is a forever learning field. For example, every pharmacist must obtain continuing education hours in order to renew their license. I do not think I fully understood how often or how much the world of pharmacy changes and one important thing pharmacists must stay on top of are new drug approvals. I would hate to be working in a pharmacy and get a new prescription for a drug I have never heard of. Therefore, I sometimes browse the FDA’s website to look at newly approved drugs and last week I saw a new approval that captured my attention.

Ashley Buehler, Pharm.D. Candidate 2015, UMKC School of Pharmacy - Columbia

Ashley Buehler, Pharm.D. Candidate 2015, UMKC School of Pharmacy – Columbia

According to the American Diabetes Association, there were 29.1 million Americans (9.3% of the population) with diabetes in 2012.1 This number has risen from 2010, when there were 25.8 million Americans with diabetes.1 Although, Type 1 diabetes can only be controlled with insulin, there are many different types of medications that can be used to control Type 2 diabetes.7 Insulin and some other Type 2 approved medications require a patient to inject themselves with a needle and personally I would not want to inject myself every day. Therefore, there has always been talk about trying to deliver insulin to patients by a different route of administration. This had been done before in 2006, when Pfizer made a drug called Exubera, which was the first inhaled form of insulin.2 But then in 2007 Pfizer took Exubera off the market due to lack of sales of the product.2

The FDA’s approval of Afrezza, an inhaled form of insulin,3 on June 27, 2014, is what caught my attention. Afrezza is manufactured by MannKind Corporation and approved for adult diabetic patients.3 This inhaled form of insulin is only to be used as a short acting control of glucose levels,3 and was approved with a Risk Evaluation and Mitigation Strategy (REMS).3

Now let’s dive into more specifics about Afrezza; it is a synthetic insulin that is inhaled by the patient.4 It comes in two different strengths, four units and eight units, which are dosed at mealtimes.4 Each strength comes as a different colored cartridge, the four units are blue and the eight units are green.4 Each cartridge must always be used with the Afrezza inhaler and the inhaler should be replaced every 15 days.4 Listed below are the steps to proper usage of the Afrezza inhaler.

Steps to Using Afrezza According to the Medication Guide4:

1.)   Select the correct number of cartridges needed based on your individual dose required. Some patients may need to use more than one cartridge of different or the same strengths.

  1. There will be a foil package that contains blister cards of the cartridges, so remove the correct number cartridges from the blister card by pressing the clear side.
  2. Important: Inhaler and cartridges must be at room temperature for 10 minutes before use.

2.)   Load the cartridge by holding the inhaler in one hand (white mouthpiece on top and purple base on bottom) and open the inhaler by lifting the mouthpiece with the other hand.

  1. Place the cartridge with the cup facing down and the pointed end of the cartridge should align with the pointed end of the inhaler.
  2. Close the mouthpiece and a snap should be heard when the inhaler is fully closed.
  3. Important: Make sure the cartridge lies flat within the inhaler and once in this flat position do not turn, point, or shake the inhaler as the drug powder may be lost.

3.)   Inhaling the powder requires multiple steps.

  1. First, remove the mouthpiece cover while still keeping the inhaler level.
  2. Exhale while the inhaler is away from your mouth.
  3. Put the mouthpiece in your mouth and tilt the inhaler down toward your chin, then close your lips to form a seal.
  4. Inhale deeply and hold your breath while removing the inhaler, then continue to hold your breath for as long as comfortable.

4.)   Remove the used cartridge by placing the mouthpiece back on the inhaler, then open the white mouthpiece, remove the cartridge, and then throw away the cartridge in the trash.

  1. Important: If you need to use more than one cartridge for your dose repeat steps two through four.
  2. Important: You can tell the difference of a new and used cartridge by the placement of the white cup. If the white cup is in the middle it is used and if it is to one side it is new.

Afrezza should be stored based on whether it has been opened or not.4 If the sealed foil packages have not been opened they should be stored within a refrigerator and can be used up to the expiration date.4 If the sealed foil package or the clear strips from the blister card have been opened they can be stored at room temperature.4 Although, the blister cards can last for 10 days, if removed from the foil package, and the clear strips only last for three days if they have been opened.4 The inhaler can be kept in the refrigerator, but do not keep the cartridges left in the inhaler.4 The inhaler can be cleaned by wiping it with a clean, dry cloth, but do not get the inhaler wet or wash it.4

Afrezza does come with a boxed warning of acute bronchospasms in patients with COPD or asthma.3 Therefore, it should not be used in patients with chronic lung conditions, such as COPD or asthma.4 It cannot be used in children under the age of 18.4 Patients should be informed to not operate heavy machinery, drink alcohol, or smoke while using Afrezza.4 The most common side effects seen with this new medication is hypoglycemia, cough, and sore throat.4 A list of warnings and precautions include: acute bronchospasm, change in insulin regimen, hypoglycemia, decline in pulmonary function, lung cancer, diabetic ketoacidosis, hypersensitivity reactions, hypokalemia, and fluid retention and heart failure with concomitant use of thiazolidinediones .5 Finally, Afrezza is pregnancy category C and there have not been studies on whether it is safe in lactating women.6

From this information it looks like Afrezza may have complicated steps to use and difficult storage directions, but it does provide the benefit of no needle sticks. Adherence is something pharmacists should worry about in their patients and Afrezza may provide an advantage as it is considered a painless route of administration when compared to injections. The FDA is requiring post-marketing studies to research safety and efficacy in pediatrics, pulmonary malignancy risks, and pharmacokinetic and pharmacodynamic studies.3 Currently, Afrezza is not yet available in pharmacies,5 but only time will tell if patients accept Afrezza or if it has the same fate as Exubera.

But I will leave you with a quote from the CEO of MannKind Corporation, Alfred Mann, the “approval of AFREZZA is an important milestone for MannKind, as today’s FDA action validates the years of clinical research and commitment that powered the development of this unique therapy.”5

Ashley Buehler
UMKC School of Pharmacy at MU
PharmD Candidate 2015
MPA Rotation Student, July 2014



1Statistics about diabetes. (2014, June 10). Retrieved from http://www.diabetes.org/diabetes-basics/statistics/

2Hitti, M. (n.d.). Sales of inhaled insulin exubera halted. Retrieved from http://www.webmd.com/diabetes/news/20071018/pfizer-quits-inhaled-insulin-exubera

3FDA approves afrezza to treat diabetes. (2014, June 30). Retrieved from http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm403122.htm

4Medication guide afrezza ® (uh-FREZZ-uh) (insulin human) inhalation powder. (2014, June). Retrieved from http://www.mannkindcorp.com/Collateral/Documents/English-US/Afrezza_MedGuide-IFU.pdf

5Mannkind corporation announces FDA approval of afrezza(R); a novel, rapid-acting inhaled insulin for the treatment of diabetes. (2014, June 27). Retrieved from http://www.news.mannkindcorp.com/phoenix.zhtml?c=147953&p=irol-newsArticle&ID=1943390&highlight=

6Label. (2014, June). Retrieved from http://www.accessdata.fda.gov/drugsatfda_docs/label/2014/022472lbl.pdf

7Medication. (n.d.). Retrieved from http://www.diabetes.org/living-with-diabetes/treatment-and-care/medication/

MPA – My Pharmacy Association

In just one short month here at the Missouri Pharmacy Association (MPA), I have learned and experienced so much.

Lara Kerwin, MPA Rotation Student June 2014

Lara Kerwin, MPA Rotation Student June 2014

When I first arrived in Jefferson City for this APPE rotation, I did not know what to expect. I had several questions: What would working within the state pharmacy association be like? How are pharmacists integrated into the Association? What sorts of other activities and programming are going on in the Association?

Since my first day, I have been amazed at all of the great projects and services that M.P.A. provides, not only for the pharmacists, pharmacy students, and pharmacy technicians of Missouri, but for patients, too. Pharmacist members of MPA are involved in their communities and local government to advance of the profession. While in Jefferson City, I have been able to attend meetings and events with MPA pharmacists to see first-hand the passion and hard work that continue to drive the evolution of the scope of pharmacy practice in Missouri. In just one month, I attended meetings about implementing the “provider tax” and participated in a C.E. about implementing viable, pharmacy-driven “falls prevention” programs. I learned about SmartPA and DirectCarePro (and other programs within the Xerox suite) and Medicaid clinical edits at the Drug Prior Authorization Committee meeting. I even met with health care professionals of five federally qualified health centers as they developed a team-based, all-encompassing approach to transform pain management for Missourians. I feel like I have seen so much, and yet this is only a glimpse into the many projects of the pharmacist members of the Missouri Pharmacy Association.

I had no idea that the Missouri Pharmacy Association was involved in so many different areas! In addition to shadowing and meeting with pharmacist members of MPA this month, I have had the opportunity to work closely with MPA’s tight-knit, dedicated staff. MPA is currently planning their annual convention, this year with the Illinois Pharmacy Association to be held in St. Louis, Missouri (It is not too late to sign up – register here!). At the convention, there will be pharmacist, technician, and student programming – including the opportunity to present posters and participate in a patient counseling competition. It will be a great place to meet fellow pharmacy advocates and like-minded, patient-centered pharmacists from our neighboring states. Another big role MPA plays is in the affairs of our state government. Located just minutes from the capitol building, MPA is heavily involved in lobbying for expanding the roles of pharmacists in our communities; for example, this year, a bill was passed to expand our vaccination protocol abilities to include Hepatitis A and B administration, as well as Tdap, to our patients aged 12 and up. In this one act of legislation alone, MPA and other stakeholders have supported the evolving role of a pharmacist and increased access to care for thousands of Missouri citizens.

I have taken a lot away from this experience to drive my future practice. Most importantly, I take with me the importance of being an active member of My (Missouri) Pharmacy Association. As a student, I have attended the annual Legislative Day and met MPA members at Missouri receptions at annual conferences, but I see now that that is not the full experience. As students of both STLCOP and UMKC, there are enormous benefits of being active student members of MPA. In addition to being able to submit clinical and opinion content for their blog and magazine, MPA can help facilitate our patient care projects, publicize our community outreach, and teach us exactly how we can advocate and make an impact in our profession – the possibilities are endless. MPA not only will support us as students, but our first year of membership as graduated pharmacists is free! The MORx.com website offers us patient education resources, pharmacy legislation updates, and even free C.E. (Don’t forget, 2015’s – we have 30 hours to complete in one year after we graduate!) If there is a project you want to work on and really want to make an impact, reach out to MPA. To learn about opportunities, contact MPA staff Sarah Luebbert at sarah@morx.com or Brittiany Turner at brittiany@morx.com.

I have enjoyed my month as a student at MPA and being able to live in beautiful Jefferson City and see its local sites and attractions (*ProTip: Central Dairy and Thursday Night Live events in June are not to be missed). As I sign off my last MPA student blog, I want to thank the MPA and Dr. Oestreich for all of the learning experiences I have had. So long, Jefferson City!

Until next time,

Lara Kerwin
UMKC School of Pharmacy
Pharm.D. Candidate 2015
MPA Rotation Student, June 2014


“Show-Me” Vaccines

Lara Kerwin, PharmD Candidate 2015, UMKC School of Pharmacy

Lara Kerwin, PharmD Candidate 2015, UMKC School of Pharmacy

As a Kansas City (K.C.) native, I take pride in my hometown for several reasons:

1)     The Kansas City Royals are off to a great start this year! We fiercely love our Royals and root for them, no matter what.

2)     Two Sporting K.C. players are on the U.S. National soccer team this year and made key plays in our win over Ghana for the U.S. to remain in contention for the 2014 F.I.F.A. World Cup.

3)     Our barbeque, entertainment, and picturesque fountains are second-to-none. K.C. is a great place to live that offers the bustle of the city, quiet suburbia, and beautiful rural areas all wrapped into one.

Despite all of these amazing attributes of Kansas City, I heard news this week of home that left me feeling uneasy. As of June 9, The Kansas City Star reported 13 cases of the measles in town, along with two other suspected cases.1

As a Kansas Citian, certified immunizer, and future pharmacist, I was disheartened when reading this news because measles are a vaccine-preventable disease.

Once contracted, measles can lead to a whole body rash, fever, and even neurologic symptoms and death.2 Measles outbreaks, however, are not isolated to the Kansas City area. Several recent reports from the Centers for Disease Control and Prevention (CDC), including the Morbidity and Mortality Weekly Report from June 6, 2014, mention that there have been 477 cases of the measles reported in 20 states (including Missouri) between January 1 and June 13 this year alone.3 Also stated in these reports, “The majority of the people who got the measles were unvaccinated.” 2

The measles were eradicated in the United States back in 2000, so these outbreaks are raising serious concerns for the public.3 The CDC posits two reasons why the measles are making a comeback.

One, the measles is still endemic to other countries, so travelers from these regions are bringing the measles virus into the United States.

Two, people traveling to these endemic measles regions are not getting the necessary travel vaccinations or have never received the vaccine and become exposed.3

In a statement to The Star, the director of the Johnson County Department of Health and Environment declared, “The best way to prevent measles is what we have known for years; make sure that you and your children are up to date on your vaccinations.” 1

This got me thinking: Why are people not receiving these vaccines? The answer is multi-fold. Some avoid immunizations because of religious beliefs or ideals. However, others fear a link between vaccines (namely, MMR) and autism due to a plethora of misinformation.4 In 1998, a doctor from the U.K. purported a causal relationship between the measles-mumps-rubella vaccine and autism by way harmful, neurotoxic proteins entering circulation via MMR-induced irritable bowel disease.5 Since its original publication in The Lancet, it was released that this doctor did not reveal several conflicts of interest pertaining to his assertions about the MMR vaccine; his medical license has since been revoked, and The Lancet retracted the article in 2010.4 All the while, countless studies have found everything to the contrary of that original article: there is no causal link between the MMR vaccine and autism.5

Similarly, the evidence suggests that thimerosal, a preservative found in some multi-dose vaccine vials, does not cause autism, either. To further discredit the misinformation about MMR vaccines, the MMR vaccine does not and has never contained the thimerosal preservative).4, 5 In a newsletter addressing “Vaccines and Autism: What you should know,” the Children’s Hospital of Philadelphia decisively states, “… [D]elaying or withholding vaccines will not lessen the [autism] risk; it will only increase the period of time during which children are at risk for vaccine-preventable diseases.”5

The recent measles outbreaks across the United States, including Missouri, provide pharmacists with an opportunity to re-educate their patients on the importance of childhood, traveling, and catch-up immunizations, as well as an opportunity for pharmacists to expand their scope of practice.

This year in the Missouri state legislature, the Senate passed bills that supported by the Missouri Pharmacy Association and others about pharmacists providing immunizations. S.B.754 now provides that pharmacists in the state of Missouri can administer Hepatitis A, Hepatitis B, and Tdap in addition to influenza, pneumococcal, meningococcal, and zoster under protocol.6,7 This increases access to convenient care for patients who do not have a primary care provider. The bill also will protect against more vaccine-preventable diseases for Missourians. However, the aforementioned vaccines administered by pharmacists are restricted to patients aged twelve and older, and the bill does not provide for pharmacists to administer the MMR vaccine.8

Why does this matter? Nearly 30% of the measles outbreak cases were in people under the age of 19 (137/477).2 Presently, 27 states allow pharmacists to administer vaccines to patients under the age of 12, while 26 states ubiquitously allow pharmacists to administer every vaccine (including MMR).9 Therefore, precedent exists for pharmacists to be able to give the MMR vaccination to populations of all ages. But without proper legal provisions, Missouri pharmacists cannot actively provide these immunizations.8

What can Missouri pharmacists do in lieu of these measles outbreaks? According to pharmacist Mitchel Rothholz, RPh, MBA and chief strategy officer of the American Pharmacists Association (APhA), pharmacists must strive for the “Immunization Neighborhood.” 9 This concept includes advocating for immunizations through providing education and motivation for our patients and facilitating immunizations by inviting authorized immunizers into our pharmacies.9 If pharmacists honor the initiative, vaccine-preventable disease can be by and large eliminated.4 By “collaborat[ing], coordinat[ing], and communicat[ing]” with key players, the “Immunization Neighborhood,” concept can be achieved to meet the health needs of surrounding communities.9

Reimbursement plans for these services, as well as our current lack of provider status federally, may initially preclude Missouri pharmacists from providing the MMR vaccine.9 However, Missouri pharmacists can still play a definitive key role in resolving this health crisis. By correcting misinformation about vaccines, practicing at the top of their licenses with the implementation of S.B. 754, and continually advocating for increased access to care by way of expanding the scope of pharmacy practice, Missouri pharmacists can do their part to restore the health and safety of our Missouri hometowns and communities.

Lara Kerwin
UMKC School of Pharmacy
Pharm.D. Candidate 2015
MPA Rotation Student, June 2014



  1. Bavley A. KC area now has 13 measles cases, all apparently linked. The Kansas City Star. June 9, 2014.
  2. Centers for Disease Control and Prevention (CDC). Measles – United States, January 1 – May 23, 2014. Morbidity and Mortality Weekly Report Early Release. http://www.cdc.gov/vaccines/pubs/surv-manual/chpt07-measles.pdf June 6, 2014;63(22):496-9. Accessed June 17, 2014.
  3. Centers for Disease Control and Prevention (CDC). Measles Cases and Outbreaks, January 1 to June 13, 2014. http://www.cdc.gov/measles/cases-outbreaks.html June 16, 2014. Accessed June 17, 2014.
  4. Hensley E and Briars L. Closer look at autism and the measles-mumps-rubella vaccine. J Am Pharm Assoc. 2010;50:736-741.
  5. The Children’s Hospital of Philadelphia Vaccine Education Center. Q&A Vaccines and Autism: What you should know. http://www.chop.edu/export/download/pdfs/articles/vaccine-education-center/autism.pdf 2012;2. Accessed June 17, 2014.
  6. Missouri Senate. 97th General Assembly. Second Regular Session [Truly Agreed to and Finally Passed] Conference Committee Substitute for House Committee Substitute for Senate Substitute No. 2 for Senate Bill No. 754. http://www.senate.mo.gov/14info/pdf-bill/tat/SB754.pdf 2014. Accessed June 18, 2014.
  7. Missouri Board of Pharmacy. Immunization FAQ. http://pr.mo.gov/boards/pharmacy/SECURED_Immunization%20Brochure_10-6_.pdf Revised October 30, 2014;1-4. Accessed June 17, 2014.
  8. Carnahan R and Kander J. Rules of Department of Insurance, Financial Institutions, and Professional Registration. Division 2220 – State Board of Pharmacy, Chapter 6 – Pharmaceutical Care Standards. Code of State Regulations. http://www.sos.mo.gov/adrules/csr/current/20csr/20c2220-6.pdf April 30, 2013;1-11. Accessed June 17, 2014.
  9. Rothholz MC. The Role of Community Pharmacies/Pharmacists in Vaccine Delivery in the United States. [PowerPoint]. Atlanta, GA: CDC Advisory Committee on Immunization Practices (ACIP); 2013. Accessed June 18, 2014.

Transforming Pain Management in Missouri’s FQHC Medical Homes

Written by:
Lara Kerwin
UMKC School of Pharmacy
Pharm.D. Candidate 2015
MPA Rotation Student, June 2014

In 2009, 180 million hydrocodone and oxycodone prescriptions were written in the United States. Alarming as that is, the statistics do not stop. More than 40% of opioid prescribing is not from pain specialists1, and now, more people die from opiate overdose than from motor vehicle accidents.

In 2010, The Centers for Disease Prevention and Control (CDC) cited that the amount of hydrocodone sold that year could supply every adult American with 5mg every 4 hours for a month.2 Also in 2010, Missouri’s overdose death rate was 17 for every 100,000 people – higher than the national average at 12.4 per 100,000.3 To fix the overdose epidemic, the CDC recommended implementing 1) a pain clinic law, and 2) a prescription drug monitoring program. Missouri currently has neither.3

On Wednesday, June 11, the Missouri Primary Care Association (MPCA) hosted a learning session on quality improvement measures for chronic pain management in Missouri’s Federally Qualified Health Center medical homes. Four healthcare centers are participating in this pilot project, running from January 2014 – February 2015. Project objectives are to implement evidence-based medicine and standardized pain-screening tools, increase utilization of electronic health records, improve patient and provider satisfaction, emphasize improving patient functionality in (independent) activities of daily living and quality of life, and improve opioid prescribing. Three essential elements of this project pose it for success.

Team-based approach
A tenet of this pilot program is the integration of all members of the health care team. Chronic pain moves beyond tissue damage to involve both emotional and sensory aspects. Previously, to treat pain was to give a pain pill, to neglect comorbidities that affect pain, or to avoid addressing pain appropriately altogether. Among conference attendees were physicians, pharmacists, nurse practitioners, psychologists, nurses, administrative personnel, information technology specialists, and other professionals. These participants are experts and leaders in their respective fields. With these healthcare experts, the project aims to utilize the “biopsychosocial” model and address comorbidities (including mental health) to provide comprehensive pain management from every angle.

Advanced management through technology
In addition to using the electronic health record whenever possible, the project also plans to use Pro-Act© (from Care Management Technologies) and an advanced urine drug screening system from Ameritox:

  • Pro-Act. This interface sorts and organizes patient Medicaid data relevant to each healthcare center. It allows each healthcare center to track prescribing and refill practices for each patient while flagging “Quality Indicators” to prompt clinical review and eliminate gaps in care. It is customizable and compatible with many electronic health record platforms. Pro-Act© offers many pharmacotherapy clinical resources, and it especially lends itself to psychotropic medicine review (which is a patient population with consistently documented co-morbid chronic pain).
  • Ameritox. Ameritox goes beyond providing the traditional work place urine drug screen (UDS) data by utilizing mass spectroscopy to analyze relative amounts of parent compound and metabolites in urine samples. Levels are cross-referenced with a database of “prescriptionally-compliant” samples to review if the patient is compliant, abusing, or potentially diverting. This UDS system also tracks for anomalies and offers genetic testing for suspected poor or rapid metabolizers.

Dispelling misconceptions and resetting patient and prescriber expectations
Opioid use and prescribing has collected its share of negative connotations and correlations over the years, especially when abuse and misuse are rampant. The project is working to eliminate these misconceptions about opioids, opioid prescribing, and chronic pain:

  • “All pain patients are drug seekers.”
    Actually, they are seeking adequate care.
  • “More pain medicine is better.” / When a prescriber does not prescribe an opioid, he or she “did nothing to treat my pain.”
    Not all patients are candidates for opioids, especially if there is a history of drug abuse and addiction – even nicotine; physical therapy and exercises may be a better option. Some pain may stem from a mental health issue or an unmanaged comorbidity. Further, opioid use in patients with chronic respiratory conditions, like COPD, puts those patients at even higher risk of respiratory depression.
    Take home point: there is more to treating chronic pain than opioids.
  • Prescriber: “Well, I have to give them something.” / “I want to maintain access to care.”
    Fear of opioid withdrawal is not a reason to prescribe opioids. Withdrawal is treatable if it becomes a problem. Maintaining access to care should always be championed, but in a responsible and evidence-based manner of prescribing.
  • Patient: “You’re referring me to a psychologist? My pain is not all in my head.”
    While the patient’s pain may not be rooted in a psychological issue, pain is a multi-faceted condition that demands analysis of biological, psychological, and social causes in order to provide the best care for the patient.
  • Concept of “curing pain” to the patient becomes a concept of “pain management.”
    Each healthcare center will develop their own plans to achieve the proposed project objectives by February 2015. If implementation is effective, this project could be applied statewide and provide a fiscally viable, clinically and socially responsible patient-centered model for chronic pain management for the state of Missouri.

1. Study: Almost half of all narcotic prescriptions written by 5% of opioid prescribers. Drug Store News. http://www.drugstorenews.com/article/study-almost-half-all-narcotic-prescriptions-written-5-opioid-prescribers Published June 10, 2014. Accessed June 11, 2014.
2. Paulozzi LJ, Jones CM, Mack KA et al. Vital Signs: Overdoses of Prescription Opioid Pain Relievers — United States, 1999—2008. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report (MMWR). November 4, 2011: 60(43); 1487-1492. Available from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm. Accessed June 11, 2014.
3. Prevention Status Reports 2013: Prescription Drug Overdose – Missouri. Centers for Disease Control and Prevention. Atlanta, GA: US Department of Health and Human Services; 2014 Available from http://www.cdc.gov/stltpublichealth/psr/prescriptiondrug/2013/MO-pdo.pdf. Accessed June 11, 2013.