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AMA House of Delegates

Dr. Annis chaired task force on pain management procedures. Photo by Peter Wynn Thompson / www.peterthompsonphoto.com

AMA meeting: Pharmacists warned on intruding into prescribing decisions

Delegates say pharmacists have been second-guessing physician decisions on drug orders; pharmacists say they're just trying to comply with DEA requirements.

By — Posted July 1, 2013

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The AMA House of Delegates adopted policy stating that a pharmacist who makes inappropriate queries on a physician's rationale behind a prescription, diagnosis or treatment plan is interfering with the practice of medicine.

If the problem isn't resolved, the American Medical Association will advocate for regulatory and legislative solutions to prohibit pharmacies from denying medically necessary treatments, the policy states. Physicians need to send a clear message to pharmacists “that they can't intrude on our practice of medicine,” said Robert Wailes, MD, an alternate delegate for the American Academy of Pain Medicine from Carlsbad, Calif.

Delegates to the Annual Meeting in June described instances in which pharmacies overstepped their roles in checking the propriety of drug orders. When ordering narcotics for patients, Melvyn Sterling, MD, an alternate delegate from the California Medical Assn. who spoke on his own behalf, said he receives faxes and calls from certain chain pharmacies asking what other medications he's tried for pain relief, as well as questions about psychiatric comorbidities.

“There are doctors, and there are pharmacists. My responsibility is to write a prescription; it's the pharmacist's responsibility to fill it,” said Dr. Sterling, a palliative care specialist from Orange County.

It is not the intent of pharmacists to intrude on medical practice, said Kevin Nicholson, the National Assn. of Chain Drug Stores' vice president for public policy and regulatory affairs. He said pharmacies have had to respond to new levels of scrutiny by the Drug Enforcement Administration, which has been investigating chain pharmacies for perceived over-dispensing of controlled substances.

DEA mandates on pharmacies “include assessing whether prescriptions for controlled substances were written for a legitimate medical purpose in the usual course of professional practice. A pharmacist cannot dispense a controlled substance unless he/she concludes that the prescription meets these criteria,” Nicholson said. Chain pharmacies query physicians to document compliance with these requirements, he said.

The AMA's new policy directs the AMA to work with NACDS, the DEA and others to develop policies on reducing inappropriate dispensing and drug diversion. “Pharmacists and physicians are in the same situation; we are both frustrated and feel there is a better way to help patients while confronting prescription drug abuse,” Nicholson said.

The National Community Pharmacists Assn. opposes the AMA resolution. It “takes a simplistic approach to the prescription drug abuse epidemic that is very complex and wide-ranging in nature,” said NCPA CEO B. Douglas Hoey, RPh.

Pain procedure supervision

In another scope-of-practice issue, delegates approved a Board of Trustees report with guidelines on invasive pain management procedures for treating chronic pain, including procedures that use fluoroscopy.

Testimony focused on the degree of supervision required for nonphysicians. Such procedures require physician-level training, but there are instances in which appropriately trained, credentialed nonphysicians could perform certain technical tasks under the supervision of experienced physicians either on site or in the same room, the report stated.

Nonphysicians “are extremely valuable, and we believe strongly that we want to work in cooperation and partnership with them,” said AMA Trustee Joseph P. Annis, MD, chair of the task force that wrote the report.

Dr. Annis said in an interview that there are treatment situations, considered on a case-by-case basis, in which physicians don't need to be on site to supervise nonphysician practitioners in a general capacity.

In cases involving radiologic imaging, however, the report specified that invasive pain management procedures should be performed only by doctors with appropriate credentials and training.

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