Comprehensive Medication Management

The Case for Comprehensive Medication Management by Pharmacists

What is comprehensive medication management?

Advantage to plan member

Immediate access to assessment services related to their medication-related needs
Realize the full benefits of prescribed medication (through enhanced monitoring and adherence to treatment)
Understand the consequences of non-adherence
Greater engagement and self-management

Advantage to employer

Greater adherence to medication regime resulting in faster recovery, reduced risk of complications, reduced absenteeism and presenteeism
Reduced or eliminated avoidable side effects
Reinforcement of good medication habits

Advantage to plan

Potential for reduced drug plan cost (from greater adherence, less abuse, and appropriate therapeutic substitutions)
Fewer (or elimination of) costly adverse events
Reduced or elimination of duplicative or interacting medications

Comprehensive Medication Management (CMM) describes a number of health care services that ultimately focus on “getting the medications right”. CMM involves collaboration with physicians, other members of a patient’s health care team, and pharmacists to provide safe, effective and appropriate drug therapy. In so doing CMM involves a coordinated and monitored effort to ensure the right drug is being taken at the right time, in the right dose to achieve optimal patient-centred health care.

How can pharmacists help?

Pharmacists are ideally positioned to provide specific medication-related activities that result in an integrated and holistic approach to CMM including:

Medication adherence
Therapeutic substitution
Narcotic and controlled drug management

Collectively these activities address high rates of preventable medication problems and adverse effects to improve patient health and reducing healthcare investment and drug plan costs.

Case study example

Here’s an example of how a pharmacist identified a case of hypertension and helped a middle-aged executive address adherence challenges (names have been changed to protect privacy).

Joe is a 52 year-old VP of sales with erratic eating habits and a sedentary lifestyle. Joe happened to be visiting his local pharmacy when the pharmacist, Alex, was conducting blood pressure screening. Alex Mayer, BScPhm, found Joe’s blood pressure was elevated and immediately referred him to his family physician and Joe started on medication..

When Joe returned to the pharmacy after a month of taking the new medication, Alex checked his blood pressure again. While improved, it was still higher than the recommended target. “I reviewed the impact of diet and exercise with Joe and recommended he monitor his blood pressure at home,” says Alex.

At Joe’s next visit to the pharmacy, Alex assessed his adherence to medication and discovered Joe only took about 70% of his medications each month. “I set Joe up with a daily pill box and activated monthly prescription refill reminders,” says Alex. Three months later, Joe’s adherence was over 90% and his blood pressure was on target.

The business case for plan sponsors

Medication adherence – “Drugs don’t work in patients who don’t take them.” (C. Everett Koop, M.D.)

Medication adherence means that patients take their medications in the right way, at the right times, in the right dosages, and with the right frequency. Getting patients to stick with prescribed medications is a recognized challenge. According to an Accenture study, up to 50% of patients do not properly adhere to their prescribed medications¹, leading to negative health effects, reduced effectiveness of treatment programs, greater risk of complications, and substantially higher drug costs.

The problem with traditional approaches to CMM

A more collaborative healthcare approach will help plan members prevent known medication-related problems including:

Dosing “mistakes” that can result in either under treatment or preventable adverse events – or both
Inappropriate, ineffective, or unnecessarily costly medication choices for the established goals of care
Duplicate or interacting medications
Avoidable side effects
Inconsistent adherence or other patient challenges or issues that directly reduce treatment success

A 2012 drug study by Green Shield Canada²; reported:

Almost 40% of plan members with high blood pressure are non-adherent and cost their plans 3.3 times more than those without high blood pressure
Over 40% of plan members with high cholesterol are non-adherent and cost their plans 3.5 times more than those without high cholesterol

Education and information is the key to better adherence

A national U.S. survey by Greenberg Quinlan Rosner Research revealed that “knowing the consequences” of non-adherence³ is a motivating factor in sticking with a medication regime. Over 50% of Americans surveyed said they would be more likely to take their prescribed medication if they were informed about the potential negative health consequences of non-adherence . By providing education and support related to a specific patient’s medication, pharmacists can clearly play a critical role in addressing adherence problems. Through intervention and repeated short-term follow-up or consultations, pharmacists have the potential to dramatically increase adherence when medication is prescribed.

The visibility and accessibility of the local community pharmacy may also be an important factor. Providing services from a familiar, non-institutional retail-like setting may prove to be more effective and conducive to the informal consultations that are required. The pharmacist, more than other health care professionals, can take advantage of their point of presence – during refills or routine visits – to confirm that patients are adhering to their prescribed treatment regimen, discuss adherence problems and challenges, and help them to develop a personal adherence action plan.

Medication adherence in action

When filling a new prescription, a pharmacist will always emphasize the importance of medication adherence, and the action to follow if a dose is missed.

If the pharmacist identifies the patient to be at risk of poor adherence (intentional or unintentional), additional counselling and services are offered. Medication adherence assessment and counselling is offered upon each subsequent patient visit. If a patient returns too early or too late for a refill, the pharmacist has the opportunity to evaluate and intervene in the patient’s non-adherence.

Point of care devices such as a blood pressure monitor and glucose meter are used to quantify the effects of poor adherence. This provides the pharmacist with a starting point to discuss non-pharmacological options and lifestyle modifications.

The pharmacist documents any intervention and/or advice offered to promote medication adherence. When appropriate, the pharmacist notifies the appropriate healthcare professionals (e.g. primary care physician, social worker, etc.) of the patient’s pharmacotherapy status.

Therapeutic Substitution – an important way for all stakeholders to contribute to the ongoing sustainability of the drug plan

Therapeutic substitution is not new. What’s relatively new is that most provinces (6 out of 10 as of May 2014) have progressively expanded the scope of a pharmacist’s role to allow for substitution without authorization from the physician. Substitution is all about substituting another drug based on the best available evidence that is expected to have the same or a similar therapeutic effect – a different drug molecule within the same class.

Substitution may occur for several reasons: the patient has previously experienced an adverse reaction to drugs; a substitution may be considered better by the pharmacist in the context of a combination of drugs, or the substitution maybe motivated by patient and/or sponsor budgetary constraints.

The switch can occur between two brand name drugs or between two generic drugs. It can also involve a switch from a brand to a lower cost generic equivalent drug. Health Canada mandates that a generic drug work the same way in the body as the original brand name drug. As such, the only difference between a generic and brand-name drug is price. Yet according to the Canadian Generic Pharmaceutical Association, “while generic drugs are used to fill more than 63% of allprescriptions in Canada, they account for only 24% of the $22.1-billion dollars Canadian spend annually on prescription drugs.”⁴

In contrast, according to the FDA, 80% of prescriptions filled in the United States are for generic drugs.⁵ Furthermore, it is estimated that generics saved the U.S. health care system $217 billion in 2012, up from $188 billion the previous year. On the private payer side, generics in the last decade have saved third-party payers $552 billon.⁶

Not surprisingly, many sponsors in Canada now mandate generic substitution when designing a benefits plan as a way to control escalating drug costs. According to Benefits Canada, “the cost savings of therapeutic substitution may provide drug savings between 4% to as much as 10% of a company’s total experience.”⁷

What’s required now is greater engagement by the end consumer – the patient and plan member. Motivating plan members to ask their pharmacist about the feasibility or desirability of safe therapeutic substitution will make them active participants in a responsive and cost-effective health care solution that works for everyone. Doing so will help ensure an affordable and sustainable health benefit plan.

Therapeutic Substitution in Action

A patient may never hear the term “therapeutic substitution”. Instead, the pharmacist may say, “I believe there is a better alternative for you. Would you like me to adapt your prescription?”

If the pharmacist identifies a therapy that would make an appropriate substitution, this change will be discussed with the patient at length. For example, the new dosing, regimen, safety profile and administration will be explained. The goal is to provide enough information for the patient to make an informed choice.

If the patient accepts a therapeutic substitution, the pharmacist will prescribe the new medication under their license. This prescription is subject to the same regulations, and can be filled in the same way, as the original prescription. In all provinces, the pharmacist prescriber must notify the original prescriber of the adaptation.

Narcotic and Controlled Drug Management

The death of actor Heath Ledger in 2008 from a drug overdose is a high profile example of catastrophic prescription drug abuse. Ledger was found dead with a potent mix of Vicodin (hydrocodone), OxyContin (oxycodone), diazepam, and alprazolam in his bloodstream.⁸

Ledger is not an isolated case: abuse of prescription drugs is a serious problem that has reached alarming levels in the U.S. and Canada. From 2005 to 2011 Ontario experienced an almost 250% increase in the number of emergency room visits related to narcotics – ranging from intoxication to withdrawal and overdose.⁹ PDFC (Partnership for a Drug-Free Canada) estimates that 350,000 Canadian youths have taken prescriptions medications not prescribed to them.¹⁰

In March 2013, the Canadian Centre on Substance Abuse (CCSA) released a 10-year plan to deal with the crisis of prescription abuse. The plan provided the first pan-Canadian strategy with five streams of action to deal with the devastating harms associated with prescription drug abuse: Prevention, Education, Treatment, Monitoring and Surveillance, and Enforcement.¹¹

Pharmacists have a key role to play in supporting this important strategy by educating patients on the proper use, storage, and disposal of unused medication – and above all, the dangers of medication misuse. Pharmacists are also in the best position to notice potential abuses. When they see prescription refills occurring faster than the prescribed dosage frequency would allow, pharmacists can take the lead by contacting the prescribing physician to alert them to the potential misuse.

In this respect, pharmacists are emerging as critical educators and gatekeepers. To support this latter role, pharmacists must be able to make the final decision, based on a careful assessment of the patient and situation, about whether to dispense a prescribed medication or take alternative action.

Narcotic and Controlled Drug Management in Action

Methadone Maintenance Treatment (MMT) starts with a physician prescribing methadone either as daily drinks or as weekly “carries”. Patients:

Take their prescription to the “drop-off” counter of a methadone dispensing pharmacy
Sign a pharmacy-patient agreement that outlines the rules and regulations regarding methadone dispensing, as well as patient duties and expectations.
Sign a dispensing sheet supplied by the pharmacist acknowledging they received their methadone drink(s) on that day

The pharmacist will also counsel the patient on methadone, how it works, potential side effects, the importance of treatment adherence, and address any questions/concerns the patient may have.

With daily drinks the patient visits the pharmacy every day. With carries, the patient receives their daily drinks for the entire week in a lock-box for security purposes.

To obtain additional drinks in the future, the patient must return their empty methadone bottles to the dispensing pharmacy.

In conclusion

If drug plans recognize the expanded role that pharmacists can play, employees will get the counsel and help they need to stay on track with their medication regimes. Pharmacists are in an ideal position to intervene and help prevent many adverse medication events as part of a comprehensive medication management. As well, pharmacists can adjust dosages, recommend a generic equivalent when appropriate and, where provincial legislation permits, write prescription for renewals or new medications, further advancing a health care plan that favors adherence and optimal drug therapy outcomes.

1. Accenture, December 2012, Understanding the value of expanded pharmacist authority in Ontario
2. GSC 2012 Drug Study, The Inside Story
3. Greenberg Quinlan Rosner Research, http://gqrr.com/articles/2013/05/02/new-initiative-to-improve-medication-adherence-unveiled-by-health-care-consumer-patient-and-industry-leaders
4. Canadian Generic Pharmaceutical Association, http://www.canadiangenerics.ca/en/resources/if_brandvsgeneric.asp
5. FDA U.S. Food and Drug Administration, http://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/understandinggenericdrugs/ucm167991.htm
6. Generic Pharmaceutical Association, Generic Drug Savings in the U.S., 2013, http://www.gphaonline.org/media/cms/2013_Savings_Study_12.19.2013_FINAL.pdf
7.Benefits Canada, January 2013, http://www.benefitscanada.com/benefits/health-benefits/considering-therapeutic-substitution-35813
8.CNN. February 6, 2008. www.cnn.com/2008/SHOWBIZ/Movies/02/06/heath.ledger/
9.http://www.ctvnews.ca/canada/medication-abuse-strategy-calls-for-more-monitoring-of-prescriptions-1.1213048
10. http://www.canadadrugfree.org/drug-info/prescription-drugs/
11. First Do No Harm: Responding to Canada’s Prescription Drug Crisis, March 2013