A partial solution to oral opiate overuse: Topical compounded Rxs

Salvatore GiorgianniTo say that there is controversy about the overuse of opiates is an understatement. It’s hard to read a healthcare journal or blog without seeing some pithy piece, bemoaning the daily conundrum practitioners are faced with. Less sociologically traumatic but equally difficult are concerns regarding oral nonsteroidal anti-inflammatory drugs (NSAIDs). Leaving the difficult discussion of why patients have so much pain aside, we are faced with an increasingly difficult set of situations.

Unfortunately, much of the discussion focuses on bemoaning opiates as a social ill or how pharmacists are hapless gatekeepers caught in a three-way tug of war between prescribers, patients, and law enforcement. Many solutions have been provided: some workable, ethical, and compassionate and others Machiavellian and ultimately injurious to our profession and patients.

The public is confused, too.  Many patients I speak with are apologetic for the occasional need of an opiate.  Most are elderly with chronic conditions that condemn them to lives of pain. Most would rather live with that pain than be self-labeled as “addicted” or suffer the extraordinary scrutiny and stigma that frequently accompanies pain management.

A constructive approach

Pharmacists have unique expertise in compounding. We are the only profession that has the training, resources, and skills to do this in a truly professional manner. Offering our expertise in the creation of patient-specific compounds for our patients and our medical and nursing colleagues is one of the most constructive ways pharmacists can help provide meaningful pain management and address concerns with opiate use.

I am not suggesting compounded topical prescriptions will eliminate opiate use or make the social issues of addiction magically go away, but the proper use of multi-component compounds, specifically prepared to address a particular patient need, is a solution to a problem that can make a difference.  Even if such compounds reduced oral opiate use by 20% or even 10%, would that not be positive compassionate progress?

In a recent case of an NSAID-intolerant worker who broke her foot while on the job, use of a multi-component compounded product was of significant clinical value. The break was painful, difficult to manage, and frustrating for both clinician and patient. One of the concerns was that because of this person’s work, chronic pain at the site of the fracture was likely. A common clinical problem like this example might lead to chronic use of increasingly powerful opiates and medical addiction. However, the pharmacist and physician worked collaboratively to create a clinically useful compound that was covered by workman’s compensation. I suspect we all know such patients.  

Plea for reasonableness

I would be remiss if I did not make a plea for reasonable reimbursement for compounded prescriptions.  It seems to me that it is incongruous for insurance companies, and those who dictate coverage, to unwaveringly and easily cover opiates but put up almost Sisyphean obstructions to obtaining appropriate reimbursement for compounds.

Note to insurance executives and corporate HR executives:  you can’t have it both ways. You can’t wring your hands about the financial and social costs of opiates and create an enabling reimbursement system for them, and at the same time block approaches to care that would in a substantial percentage of cases mitigate their need.

What can we do collectively and individually?

Meet with local practitioners to talk about topical pain management compounds. Don’t just limit this to so-called pain management practices. Primary care practitioners are as frustrated as we are with how to manage pain patients and avoid the addiction-care conundrum.

Offer to give CME programs at local medical, nursing, and physician assistant meetings and colleges.

Promote the professionalism and ethics of compounding at every opportunity.

Consult with pain patients about availability and effectiveness of these agents.

If you do compounding, do it in a way that would make the most finicky pharmacy professor happy, or at least not displeased and counsel patients on how to use these and what to expect from them.

Expect pushback from various sectors, professional and commercial, which see this as a threat, but be vociferous in defense of our patients, sensibility, and our profession.

Dr. Salvatore J. Giorgianni, Jr., is a consultant pharmacist and president of Griffon Consulting Group, Inc., an advisory board member for Pharmacist Partners, LLC and Drug Topics, and chair, American Public Health Association Men’s Health Caucus.