By Annette M. Boyle
FALLS CHURCH, VA – The DoD has successfully reversed a trend toward increased use of opioids by engaging pharmacists in oversight and management of polypharmacy patients in Warrior Transition Units. Now, the Army hopes to achieve even better results by embedding pharmacists in similar roles in patient-centered medical homes (PCMH).
In recent years, DoD has recognized the risks of prescription drug abuse, dependence, withdrawal and impaired thinking posed by increased medication use and particularly polypharmacy and has taken several steps to combat it. At the same time, it has expanded the options for pain management available to servicemembers.
DoD defines polypharmacy as a prescription for four or more of any type of medication, including one or more opioids within the previous 30 days, or prescriptions for four or more medications from the seven categories of drugs affecting mental state and central nervous system depressants within the last month, or three or more emergency department visits in the past year in which an opioid was prescribed at each visit.
In 2004, 5% of all active duty servicemembers (ADSM) who received one or more opioid prescriptions in a given year used opioids for 90 or more days within a six-month period. That rate of chronic opioid use rose to 5.5% in 2006 before dropping to 3.5% in 2009 and 3.0% in 2013. Among those in the Army, the rates were slightly higher, 6% in 2006,dropping to 4.5% in 2009 and 3.7% in 2013, according to the Office of the Army Surgeon General.
The risk of medication overuse or abuse has been greatest among injured servicemembers. “The management of multiple medications in the wounded warrior population is of importance to the DoD in the areas of patient safety, accidental overdose and suicide prevention,” said George E. Jones, Jr., PharmD, Chief, Pharmacy Operations Division of the Defense Health Agency (DHA).
To mitigate those risks, the Army involved clinical pharmacists in medication management in warrior transition units. “This gives extra focus to high-risk patients and helps ensure the appropriate use of medications by reviewing and reconciling medication profiles of all soldiers in a WTU,” according to the Office of the Army Surgeon General. Pharmacists assist in both baseline medication reviews for each wounded warrior within the first 24 hours of arrival in a WTU and a comprehensive medication review within five days of arrival. The pharmacists then conduct reviews at least once per week for all high-risk soldiers.
High-risk patients are enrolled in the sole provider lock-in program, so that only a specific provider or alternate may write prescriptions. Some patients also are restricted to filling prescriptions at one pharmacy.
Now, the Army is looking to bring these medication-management tools and pharmacists more directly into polypharmacy management in new contexts. The National Defense Authorization Act for fiscal year 2015 directed the DHA to conduct a pilot program aimed at clinical pharmacists providing medication-therapy management to beneficiaries with more than one chronic condition and prescribed more than one medication.
The Army has designated funds for fiscal years 2016-2020 to support the integration of clinical pharmacists in the PCMHs to expand polypharmacy screening and intervention as well as discharge-medication case management and reducing chronic disease burden.
“Army Medicine recognizes the expanded role of clinical pharmacists to address polypharmacy, the use of medications to treat chronic conditions and adverse drug events that lead to hospital admissions. Integrating clinical pharmacists into the PCMH results in decreased overall healthcare costs, fewer adverse drug events, reduced hospital admissions and improved patient outcomes,” according to the Office of the Army Surgeon General.
Within the medical homes, clinical pharmacists will work with patients to optimize adherence to appropriate drug therapy, resolve medication problems and recommend effective treatment options, especially for patients with chronic conditions and pain.
As part of a move away from reliance on narcotics and surgery for managing pain, clinical pharmacists also support the Army’s interdisciplinary pain-management centers. The nationally recognized centers take a multimodal and multidisciplinary approach to pain care, including therapies such as yoga, massage, acupuncture, biofeedback and physical therapy, all designed to improve function and quality of life.
For those servicemembers with complex medical conditions or medication regimens who are at risk of medication overuse or abuse, the DHA offers a variety of tools for use by pharmacists and providers across all services, according to Jones. These include:
- Prescription restriction program or sole provider lock-in program, which enables providers to establish pharmacy and prescriber restrictions;
- Polypharmacy medication analysis and report tool (Poly-Mart), which identifies active duty service members who meet the polypharmacy screening requirements;
- Warriors in transition unit medication analysis and report tool (WTU P-MART) for those monitoring wounded warriors, particularly for psychotropic and pain medications;
- Deployment prescription medication analysis and reporting tool (P-MART) to screen active duty members prior to deployment; and
- Controlled drug medication analysis and reporting tool (CD-MART) to help providers monitor the use of controlled medications.
More than a dozen military treatment facility pharmacies have implemented a pilot customer service system that gives patients greater control over how they spend their time while waiting for prescriptions to be filled.
Venous thromboembolism, which includes deep venous thrombosis and pulmonary embolism, is the most common preventable cause of hospital death, according to the VA.