Expert Perspectives in the Management of Opioid Induced Constipation - Episode 4

The Role of Specialty Pharmacies in the Management of Opioid-Induced Constipation

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William F. Peacock, MD; Conar Fitton, MD; and Neel Mehta, MD, reviews the position of pharmacies in providing patients with opioid-induced constipation with the necessary medication to decrease hospitalization and cost of medication.

William F. Peacock, MD: What role do specialty pharmacies play in providing patients support needed for OIC [opioid-induced constipation] care?

Conar Fitton, MD: We use specialty pharmacies for approvals for medications and things like that because sometimes the approval process requires trials of certain laxatives. When you look at the GI [gastrointestinal] guidelines for what we consider failure of first-line therapies, you generally want patients to have symptoms for at least 4 days within the first 2 weeks despite the number of laxatives that they’ve tried. But usually you can recognize that even earlier for patients who may have a baseline mild constipation who then get exacerbated to severe symptoms earlier.

We proactively round in the hospital in the intensive care unit and on the floor for patients who are going to need certain therapies as an outpatient and opioid prescriptions for a particular period of time. Or maybe they’re a chronic noncancer pain patient. With the specialty pharmacies, we usually try to get ahead of that, where if we’re transitioning from something when someone’s moving from the hospital to the outpatient setting, we try to do it a little earlier so everything gets approved ahead of time. Generally, the cost savings is massive. The data regarding the decrease in hospitalizations is impressive. I can’t tell you how many times we get called on Friday afternoon because someone hasn’t had a bowel movement since the prior Friday afternoon—but everything else is healing great and they’re ready to go home. If we could have only recognized that earlier and intervened, then we wouldn’t be in that situation.

Neel Mehta, MD: Yes. The specialty pharmacies have done a great job making it easier to access these treatments. Many times, the pharmacists are familiar. They have the drugs in stock. The turnaround time is quick. Sadly, you may make the burden so hard to be able to get access to the drug that a patient ultimately doesn’t get it, which may be part of the design of these processes along the way. But in the end, we already have talked about how these patients truly need help, so we want to make that process as easy as possible, because specialty pharmacies have made that an easier process for all parties involved.

William F. Peacock, MD: Yes. One of the challenges I have in the emergency department [ED] is I can only use the drugs that are on the formulary. If it’s not on the formulary, I can’t. I can prescribe whatever I want in the outpatient world, but for IV [intravenous] and subcutaneous drugs, that’s hard. Patients don’t want to do that themselves for the first time in their house. If I can’t do it first in the ED, it isn’t going to happen. Patients don’t want to do anything that’s IV or subcutaneous. There’s a lot of pushback. I’m really limited with that.

Neel Mehta, MD: What happens when you prescribe something to send them home with and they don’t necessarily get access to that? What’s the process there?

William F. Peacock, MD: You’ll see them back in about 4 or 5 days. They come back to you or they see their doctor in the outpatient world. That’s why the ED is always packed on Sundays: there’s no place for them to go. Their doctors’ offices are usually closed on Saturday and Sunday. They’ve been miserable long enough. They can’t take it anymore and show up. I either have to fix them or admit them, but there are no other options—especially with OIC—because you can’t throw them out. This has been a big challenge for the emergency department, especially with the formulary challenge, because you can’t use a number of drugs that work very well for certain conditions. This becomes how to figure a way around that.

Conar Fitton, MD: Medicine has changed a little, which has made it a little more challenging too. Because even when I started practicing just over 10 years ago, a lot of times the primary care providers were the ones who were seeing the patients in the hospital, and then they knew exactly what injury they had and what they were going home with. Now the practices are so busy and the hospitals are inundated with patients. Trying to bridge that transition of what they needed and got as an inpatient and when they can get in to see their doctor is where the unfortunate burden often falls on the ED, because there’s nowhere for them to go. I’ve certainly noticed that transition over the past 10 years.

Transcript Edited for Clarity