I greatly value the professional expertise of clinical pharmacists.  Here is how they could and should function:

1. As members of a healthcare team and or in actual and direct collaboration with healthcare provides.  This actually already happens in Long term care where poly pharmacies, including antipsychotic, opioids, and numerous High fish geriatric medications.  This is SETMA’s clinical decision support tool for reducing the use of antipsychotics:  Tutorial for SETMA’s Deployment of the Texas Department of Aging and Disability Services' Reduction of Antipsychotic Medications Toolkit. This was developed from a publication by the Texas Department of Aging and Disability Services. This is the product of an ideal collaboration between clinical. Pharmacists, Public Policy Experts and Health care providers. 

It does not include a provision for pharmacists, pharmacy benefit managers (PBM), and/or primary care providers, employed by retail pharmacies, to counsel patients and or to limit access to medications when they do not have medical records of the patient, and do not have a HIPAA Compliant right to review the records which are available. 

For pharmacists who are filling a medication to contact the provider and to question the prescription, in my judgement is excellent. This is what happens with the staff pharmacist in a nursing home recommends a change in a medicine.  A verbal or written communication takes place and a agreed upon change or continuation takes place. 

2. I have some concern about “drug store” managers, who are licensed  pharmacists to function in this role. There is no place, I think for pharmacists, who are not licensed or credentialed for Prescribing medications to make unilateral judgments about a prescription.  I thing the professional responsibility of a pharmacists ie to first consult with the prescribing provider. If a reconciliation cannot be achieved, in the interest of patient safety, the pharmacist has the right and responsibility not to fill the prescription, but does not, I think, have the authority unilaterally and independently to change the dosage, directions or quantity of the medication  in that the only authority the PBM has derives from the license of the pharmacist filling the prescription, they, I think, are bound to the same rules and regulations.


3. In an eight-part series on opioid addiction, I addressed issues of excessive prescribing of and dispensing od opioids: 

The Opioid Epidemic: Part I The Problem.  At the end of the articles there are links to the other seven articles in the series. The last article addresses “the solution.”   I believe, as you do, that the problem starts with physicians. You are kinder than I am about the magnitude of provider responsibility. This is the same as when dealing with our health cost conundrum, I reject insurance companies and trial lawyers as the culprits.  (See:  Entrepreneurism versus Professionalism Part II: Republicans and Democrats Both Have it Wrong)

In the case of drugs, abuse and or overuse requires the complicity of pharmacists.  And, just as they are part of the problem and to the same degree, they can and should be part of the solution. Butt, the solution must be within the law and within the licensure scope of each team member. PBMs cannot usurp the legal scope of physicians nor can they allow them pharmacists to do so.  

There is more but this is a start.  I hope you don’t mind my sharing this response with others who share our interest and who value your work 

Adjunct Professor
 Family & Community Medicine
UT Health San Antonio
Joe R. and Teresa Lozano Long School of Medicine 

Clinical Associate Professor
Department of Internal Medicine
School of Medicine
Texas A&M Health Science Center 

On Oct 6, 2017, Anna Lembke wrote:

Hi Larry,

Again it was a pleasure to meet you. Thank you for attending not one but two of my talks, and for your kind words and insightful commentary. I learned from you as well.

I was able to read your report on CVS on the plane this morning. I was interested to learn that CVS has moved into the business of providing medical care. That was something I was not aware of and it is good for me to know. I do think pharmacists can and should play a role in combatting prescription opioid misuse. Since you don't agree with a 7 day limit, what do you think pharmacists and pharmacies can and should do.

Warmly,
Anna

Anna Lembke, MD
Medical Director, Addiction Medicine
Chief, Addiction Medicine Dual Diagnosis Clinic
Program Director, Addiction Medicine Fellowship
Associate Professor, Department of Psychiatry and Behavioral Sciences
Courtesy faculty appointment, Department of Anesthesiology and Pain Medicine
Stanford University School of Medicine
401 Quarry Road
Stanford, CA
94305