Using MedsASSIST is “not just about saying ‘no’,” Guild Victorian Branch president Anthony Tassone has reminded pharmacists.
“Every day there will be patients presenting to pharmacy that have been declined supply of a codeine containing analgesic product, or the pharmacist will consider declining supply – it’s important to remember that MedsASSIST is a clinical decision-making support tool to assess the clinical appropriateness of a codeine-containing product,” Tassone told the AJP.
“Deciding that codeine is not the most appropriate product is only one step in that process, should a pharmacist make that decision.”
A chronic pain sufferer reached out to the AJP this week to tell us of her experiences being denied codeine-containing analgesics since MedsASSIST was rolled out; she says that to date no pharmacist has attempted to open a conversation about pain management and medicines use with her.
Jackie’s story is a “timely reminder for pharmacists to consider other aspects of care” such as referral or talking about other pain relief alternatives to codeine, Tassone says.
Pain expert and pharmacist Joyce McSwan says that when it comes to complex, chronic pain conditions, lack of collaboration between GPs and pain and other specialists – often resulting in inadequate pain management – stories like Jackie’s are all too common.
“Sadly, that’s the norm,” she says.
“A lot of the time everyone [in a patient’s health care team] will be saying, ‘It’s not my problem, I just do this bit’.
“If a pharmacist truly wants to do something about it, and this lady isn’t the only one, there’s multiple people with this problem – here’s an opportunity to sit down with the GP and say, ‘I want to be a responsible health care professional and understand what’s going on here. How can we work better?’ That’s a start.”
She says that it’s very useful to maintain working relationships with other health care professionals in order to recommend them to patients who feel that they are not being managed well.
“That takes a pharmacist actually wanting to do it,” she says.
“I’m sure every pharmacist has at least one GP who they may get along with. I would ring that GP and say, ‘Who’s your favourite psychiatrist and pain specialist?’ It’s just like finding a plumber or an electrician: we go by word of mouth.
“If a patient comes to me and says, ‘my pain specialist is so good!’ I say, ‘Who is it?’ I’m building a database of all these mates.
“Then I ring up that pain specialist or psychiatrist and say, “Hi, I’m Joyce from Downtown Pharmacy, my patient has come in unsatisfied with some care team members, are you taking referrals? Are you okay if I drop your name into my GP who doesn’t know you exist?’
“Who would say no?”
McSwan says that there are two main issues when it comes to using MedsASSIST: its use as a gatekeeping tool, and the way pharmacists are talking about the tool itself.
“I think the word ‘policing,’ needs to be dropped entirely from the way we think about MedsASSIST, and that we need to use the words ‘assessing tool’ instead,” McSwan told the AJP.
“The word ‘policing’ came about when Project Stop was implemented and the police were involved because of the data. This data about codeine doesn’t go to a policeman, and if it did he wouldn’t give a hoot.
“This is an assessment tool: you’re using to assess the patient. And what are you really assessing? Usually you’re assessing the indication of use – what is the patient using it for? – and is it having some long-term benefit?
“What can we do to achieve some better long-term outcomes? The sowing of those seeds in conversation with the patient are important – explaining to them the strength of the molecule itself and what they’re getting at the end of the line.”
Giving patients the facts about codeine’s effects on the body – and other painkillers used in combination, such as ibuprofen, which McSwan points out is not good long term for inflammation – helps empower them, she says.
“When you tell the patient this, you’re sticking with the facts. And I think it would be very helpful for a patient to think, ‘I’m clearly not using this efficiently enough’. You let them come to that conclusion: provide the facts and say, ‘What do you reckon? Let’s find something that will give you better outcomes’.
“I believe very much in patient autonomy,” says McSwan. “But for the patient to have that autonomy, they have to have the information they need. Nobody can have real autonomy without unbiased information.”
She says that the worst thing a pharmacist can do is tell a patient that they are required to enter a patient into MedsASSIST because “the Government requires it”.
“This is a failed statement already,” she says.
“One, it’s not true. Two, you’re saying, ‘I don’t support this but I’ve got to do it anyway’. If you’re not invested in doing it, don’t do it.
“If you are using it, use it with the right motivation in mind: that this is a great tool to help people with pain conditions if you talk to them with questions and thoughts as to what codeine is doing for them.
“If you don’t, we won’t have anything to say when the TGA is talking about upscheduling it: it’ll go S4 and then we won’t have the right to cry about it.”