Screening Controlled Substance Screening Controlled Substance - - PowerPoint PPT Presentation

Screening Controlled Substance Screening Controlled Substance Screening Controlled Substance Screening Controlled Substance Prescriptions For Legitimacy: Prescriptions For Legitimacy: The VIGIL System The VIGIL System

David B. Brushwood, David B. Brushwood, R.Ph R.Ph., J.D. ., J.D. Professor of Pharmaceutical Outcomes & Policy Professor of Pharmaceutical Outcomes & Policy The University of Florida The University of Florida

There Is A Storm Brewing There Is A Storm Brewing

• Patients in pain need their

Patients in pain need their medications and they don’t medications and they don’t y deserve pointless hassles. deserve pointless hassles.

• Abuse of Prescription

Abuse of Prescription Medications is Increasing Medications is Increasing Medications is Increasing. Medications is Increasing.

• Drug Diverters Target

Drug Diverters Target Pharmacies. Pharmacies. Th F il P Th F il P

• The Failure to Prevent

The Failure to Prevent Diversion is Costly in Diversion is Costly in Economic and Social terms. Economic and Social terms.

• It is Easy to Confuse

It is Easy to Confuse Successful Practice With Successful Practice With Diversion. Diversion.

• All Parties Share This

All Parties Share This Concern. Concern.

Definitions Definitions

(Federation of State Medical Boards) (Federation of State Medical Boards)

• Pain: “An unpleasant sensory and emotional

Pain: “An unpleasant sensory and emotional

• Pain: An unpleasant sensory and emotional

Pain: An unpleasant sensory and emotional experience associated with actual or potential experience associated with actual or potential tissue damage or described in terms of such tissue damage or described in terms of such damage.” damage.”

• Chronic Pain: “Chronic pain is a state in which pain

Chronic Pain: “Chronic pain is a state in which pain persists beyond the usual course of disease or persists beyond the usual course of disease or healing of an injury, or that may or may not be healing of an injury, or that may or may not be associated with an acute or chronic pathologic associated with an acute or chronic pathologic associated with an acute or chronic pathologic associated with an acute or chronic pathologic process that causes continuous or intermittent pain process that causes continuous or intermittent pain

• ver months or years ”
• ver months or years ”
• ver months or years.
• ver months or years.

The Pharmacist’s Dilemma The Pharmacist’s Dilemma The Pharmacist s Dilemma The Pharmacist s Dilemma

The Therapeutic Imperative:

The Therapeutic Imperative: e e apeut c pe at e e e apeut c pe at e “Always dispense opioid analgesics, and other “Always dispense opioid analgesics, and other controlled substances, when they are controlled substances, when they are i f i ” i f i ” appropriate for a patient.” appropriate for a patient.” Help the patients who need help. Help the patients who need help.

The Regulatory Imperative:

The Regulatory Imperative: “Never dispense opioid analgesics when they are “Never dispense opioid analgesics when they are “Never dispense opioid analgesics when they are “Never dispense opioid analgesics when they are inappropriate for a patient.” inappropriate for a patient.” Push the pushers out of the pharmacy Push the pushers out of the pharmacy Push the pushers out of the pharmacy. Push the pushers out of the pharmacy.

Federal Law: Federal Law: Corresponding Responsibility Corresponding Responsibility

21 CFR 21 CFR § 1306 04 Purpose of Issue of Prescription 1306 04 Purpose of Issue of Prescription 21 CFR 21 CFR § 1306.04 Purpose of Issue of Prescription 1306.04 Purpose of Issue of Prescription (a) A prescription for a controlled substance to be effective must (a) A prescription for a controlled substance to be effective must be issued for a be issued for a legitimate medical purpose legitimate medical purpose by an individual by an individual practitioner acting in the practitioner acting in the usual course of his professional usual course of his professional practice

• practice. The responsibility for the proper prescribing and

. The responsibility for the proper prescribing and dispensing of controlled substances is upon the prescribing dispensing of controlled substances is upon the prescribing dispensing of controlled substances is upon the prescribing dispensing of controlled substances is upon the prescribing practitioner, but a practitioner, but a corresponding responsibility corresponding responsibility rests with the rests with the pharmacist who fills the prescription. An pharmacist who fills the prescription. An order purporting to

• rder purporting to

be a prescription be a prescription issued not in the usual course of professional issued not in the usual course of professional be a prescription be a prescription issued not in the usual course of professional issued not in the usual course of professional treatment or in legitimate and authorized research is not a treatment or in legitimate and authorized research is not a prescription and the person prescription and the person knowingly knowingly filling such a purported filling such a purported prescription, as well as the person issuing it, shall be subject prescription, as well as the person issuing it, shall be subject to the penalties provided for violations of the law. to the penalties provided for violations of the law.

The Key To Compliance: The Key To Compliance: G VIGIL VIGIL

How can pharmacists meet the needs of

How can pharmacists meet the needs of

How can pharmacists meet the needs of

How can pharmacists meet the needs of chronic pain patients and avoid chronic pain patients and avoid “knowingly” filling purported prescriptions? “knowingly” filling purported prescriptions? knowingly filling purported prescriptions? knowingly filling purported prescriptions?

Suggestion:

Suggestion: VIGIL

VIGIL

Verification

erification

Identification

dentification

Generalization

eneralization

• Interpretation

nterpretation

Legalization

egalization

Good and Bad Decisions Good and Bad Decisions

What is our What is our Dirty Little Secret Dirty Little Secret?

State of the World

Patient Is Legitimate Patient NOT Legitimate

State of the World

g Pain Patient* g Pain Patient Opioids are

Good Bad

Prescribed/ Dispensed

Good Decision Bad Decision

HCP A ti it

Opioids NOT Prescribed/ Dispensed

Bad Decision Good Decision

Activity

p

*Assume that opioids are appropriate therapy for the patient.

Bad Decisions Cannot Be Eliminated Bad Decisions Cannot Be Eliminated Bad Decisions Cannot Be Eliminated Bad Decisions Cannot Be Eliminated

State of the World

Patient Is Legitimate Patient NOT Legitimate

State of the World

g Pain Patient* g Pain Patient Opioids are

Good Bad

Prescribed/ Dispensed

Good Decision Bad Decision

HCP A ti it

Opioids NOT Prescribed/ Dispensed

Bad Decision Good Decision

Activity

p

*Assume that opioids are appropriate therapy for the patient.

Using Balance to Using Balance to Reduce Bad Decisions Reduce Bad Decisions

State of the World

Patient Is Legitimate Patient NOT Legitimate

State of the World

Legitimate Pain Patient* Legitimate Pain Patient Opioids are

Good Bad

Opioids are Prescribed/ Dispensed

Good Decision Bad Decision

HCP A ti it

Opioids NOT Prescribed/

Bad Decision Good Decision

Activity

Dispensed

Decision Decision

*Assume that opioids are appropriate therapy for the patient.

Distinguishing Pain Behaviors Distinguishing Pain Behaviors From Suspect Behaviors From Suspect Behaviors

There is confusion between patients with the

There is confusion between patients with the p disease of addiction and those with the disease disease of addiction and those with the disease

• f pain.
• f pain.

Focus on the impact of medication on patient

Focus on the impact of medication on patient

Focus on the impact of medication on patient

Focus on the impact of medication on patient function, when opioids are provided: function, when opioids are provided:

Increased function = desired use (patient has disease

Increased function = desired use (patient has disease

• f pain)
• f pain)
• f pain)
• f pain)

Decreased function = undesirable use (patient has

Decreased function = undesirable use (patient has disease of addiction) NB: Perhaps also the disease of disease of addiction) NB: Perhaps also the disease of pain pain pain pain

We must filter out red herrings

We must filter out red herrings

Dose, frequency, duration.

Dose, frequency, duration.

Physician “reputation.”

Physician “reputation.”

Patient appearance.

Patient appearance.

Is It Addiction? Is It Addiction? Is It Addiction? Is It Addiction?

Addiction is … characterized by behaviors that include

Addiction is … characterized by behaviors that include y

• ne or more of the following:
• ne or more of the following:

Impaired control over drug use

Impaired control over drug use

Compulsive use

Compulsive use p

Continued use despite harm

Continued use despite harm

Craving

Craving

The behaviors of pain patients may seem similar to

The behaviors of pain patients may seem similar to

The behaviors of pain patients may seem similar to

The behaviors of pain patients may seem similar to those of addicts, but the goals are different. those of addicts, but the goals are different.

Relief

Relief-

• seeking (aggressive demand) v. Drug

seeking (aggressive demand) v. Drug-

• seeking

seeking

“Polypharmacy” (co

“Polypharmacy” (co morbidities: insomnia anxiety depression) morbidities: insomnia anxiety depression)

• Polypharmacy (co

Polypharmacy (co-morbidities: insomnia, anxiety, depression) morbidities: insomnia, anxiety, depression)

Doctor shopping (if under treated).

Doctor shopping (if under treated).

Aberrant behaviors (doubling up, sharing, borrowing, other

Aberrant behaviors (doubling up, sharing, borrowing, other indication hoarding) indication hoarding) indication, hoarding). indication, hoarding).

Non

Non-

• Addict Drug Pushers

Addict Drug Pushers

FSMB Pain Mgt Policy FSMB Pain Mgt Policy FSMB Pain Mgt. Policy FSMB Pain Mgt. Policy

“Addiction”

“Addiction” -

• “a neurobehavioral syndrome

“a neurobehavioral syndrome with genetic and environmental influences that with genetic and environmental influences that with genetic and environmental influences that with genetic and environmental influences that results in psychological dependence on the use results in psychological dependence on the use

• f substances for their psychic effects and is
• f substances for their psychic effects and is
• f substances for their psychic effects and is
• f substances for their psychic effects and is

characterized by compulsive use despite characterized by compulsive use despite harm.” “Physical dependence and tolerance harm.” “Physical dependence and tolerance

• harm. Physical dependence and tolerance
• harm. Physical dependence and tolerance

are normal physiological consequences of are normal physiological consequences of extended opioid therapy for pain and should extended opioid therapy for pain and should extended opioid therapy for pain and should extended opioid therapy for pain and should not be considered addiction.” not be considered addiction.”

FSMB Pain Mgt Policy FSMB Pain Mgt Policy FSMB Pain Mgt. Policy FSMB Pain Mgt. Policy

• “Tolerance”

“Tolerance” -

• “the need to increase the dose of opioid

“the need to increase the dose of opioid to achieve the same level of analgesia.” “does not to achieve the same level of analgesia.” “does not t ith ddi ti ” t ith ddi ti ” equate with addiction” equate with addiction”

• “Physical Dependence”

“Physical Dependence” -

• “physiologic state of neuro

“physiologic state of neuro-

• adaptation characterized by emergence of withdrawal

adaptation characterized by emergence of withdrawal adaptation characterized by emergence of withdrawal adaptation characterized by emergence of withdrawal syndrome if drug use is stopped or decreased syndrome if drug use is stopped or decreased abruptly ” “does not equate with addiction ” abruptly ” “does not equate with addiction ”

• abruptly. does not equate with addiction.
• abruptly. does not equate with addiction.
• “Pseudoaddiction”

“Pseudoaddiction” -

• “pattern of drug

“pattern of drug-

• seeking

seeking behavior of pain patients who are receiving behavior of pain patients who are receiving behavior of pain patients who are receiving behavior of pain patients who are receiving inadequate pain management and can be mistaken inadequate pain management and can be mistaken for addiction” for addiction”

FSMB Pain Mgt Policy FSMB Pain Mgt Policy FSMB Pain Mgt. Policy FSMB Pain Mgt. Policy

Evaluation

Evaluation

• Consultation

Consultation

complete history and

complete history and physical exam physical exam d t d d t d

• refer if necessary

refer if necessary

• Medical Records

Medical Records documented documented

Treatment Plan

Treatment Plan

therapeutic goals

therapeutic goals

• complete and accurate

complete and accurate

• Compliance with

Compliance with Controlled Substance Controlled Substance

therapeutic goals,

therapeutic goals, further evaluations further evaluations

Informed Consent

Informed Consent Controlled Substance Controlled Substance Laws Laws

Periodic Review

Periodic Review

reasonable intervals

reasonable intervals

The Ambiguity of “Red Flags” The Ambiguity of “Red Flags”

“Flag” “Flag” Regulators Regulators Pharmacist Pharmacist

• Pts. Come from
• Pts. Come from

miles away miles away Pill Shop Pill Shop Specialty practice Specialty practice Multiple symptoms Multiple symptoms treated treated Polypharmacy Polypharmacy Holistic care Holistic care High Doses High Doses No medical need No medical need Lethal Lethal Individualized Individualized care care

• Pt. Asks for drugs
• Pt. Asks for drugs

by name by name Addiction Addiction

• Pt. accepting
• Pt. accepting

responsibility responsibility Returns too early Returns too early Dealing Dealing Crisis Crisis

DEA Pharmacist’s Manual DEA Pharmacist’s Manual

Pharmacist’s Guide to Prescription Fraud Pharmacist’s Guide to Prescription Fraud

“Characteristics of Forged Prescriptions” “Characteristics of Forged Prescriptions” Characteristics of Forged Prescriptions Characteristics of Forged Prescriptions “1. Prescription looks “too good”; the prescriber’s “1. Prescription looks “too good”; the prescriber’s handwriting is too legible.” handwriting is too legible.” handwriting is too legible. handwriting is too legible. “2. Quantities, directions or dosages differ from usual “2. Quantities, directions or dosages differ from usual medical usage.” medical usage.” g “3. Prescription does not comply with the acceptable “3. Prescription does not comply with the acceptable standard abbreviations or appears to be textbook standard abbreviations or appears to be textbook presentations.” presentations.” “4. Prescription appears to be photocopied.” “4. Prescription appears to be photocopied.” “5. Directions written in full with no abbreviations.” “5. Directions written in full with no abbreviations.”

DEA Pharmacist’s Manual DEA Pharmacist’s Manual

Pharmacist’s Guide to Prescription Fraud Pharmacist’s Guide to Prescription Fraud

“P ti T h i ” “P ti T h i ” “Prevention Techniques” “Prevention Techniques”

“Know the prescriber and his/her signature.”

“Know the prescriber and his/her signature.”

“Know the prescriber’s DEA registration

“Know the prescriber’s DEA registration number.” number.”

“Know the patient.”

“Know the patient.”

“Check the date on the prescription order

Has “Check the date on the prescription order Has

Check the date on the prescription order. Has

Check the date on the prescription order. Has it been presented to you in a reasonable length it been presented to you in a reasonable length

• f time since the prescriber wrote it?”
• f time since the prescriber wrote it?”
• f time since the prescriber wrote it?
• f time since the prescriber wrote it?

The VIGIL Process The VIGIL Process Preventing the “Battle of Your Town” Preventing the “Battle of Your Town”

• r “How to Avoid Starring in the Brushwoods’ Next Video”
• r “How to Avoid Starring in the Brushwoods’ Next Video”
• r Responding to Dr. Fisher’s Claim That “There is No Safe Harbor”
• r Responding to Dr. Fisher’s Claim That “There is No Safe Harbor”

Verification erification I dentification dentification G li ti li ti

Not necessary

Not necessary if you know a if you know a prescription is valid. prescription is valid. Not useful Not useful if you know a if you know a Generalization eneralization I nterpretation nterpretation Legalization egalization

Not useful

Not useful if you know a if you know a prescription is invalid. prescription is invalid.

Use For “in between”

Use For “in between” Legalization egalization prescriptions ( prescriptions (Tweeners Tweeners). ).

Recommended: Take a

Recommended: Take a “universal precautions universal precautions” “universal precautions universal precautions” ” approach approach

Verification Verification

Answers the question: “Is this a responsible opioid

Answers the question: “Is this a responsible opioid user?” user?”

Talk with the patient.

Talk with the patient.

Do not fill C

Do not fill C-

• II opioid or hydrocodone/acetaminophen

II opioid or hydrocodone/acetaminophen for the first time without verifying with the prescriber for the first time without verifying with the prescriber for the first time without verifying with the prescriber. for the first time without verifying with the prescriber.

Find out the purpose (“legitimate medical purpose”) of

Find out the purpose (“legitimate medical purpose”) of the medication (not the diagnosis), the medication (not the diagnosis), if you can if you can.

Alternative to calling prescriber is a trusted colleague

Alternative to calling prescriber is a trusted colleague who may vouch for the patient. who may vouch for the patient.

May provide partial supply if “unable to supply” full

May provide partial supply if “unable to supply” full

May provide partial supply if unable to supply full

May provide partial supply if unable to supply full quantity due to inability to verify. 72 hours for quantity due to inability to verify. 72 hours for balance. balance. b l ll f f b l ll f f

Responsibility continues over time. Call for verification

Responsibility continues over time. Call for verification if questions arise. Fax back thanks, and keep fax. if questions arise. Fax back thanks, and keep fax.

Identification Identification Identification Identification

Answers the question: “Do I know for sure

Answers the question: “Do I know for sure

Answers the question: Do I know for sure

Answers the question: Do I know for sure who this person is?” who this person is?”

Require government issued photo ID of

Require government issued photo ID of

Require government issued photo ID of

Require government issued photo ID of anyone picking up Rx for C anyone picking up Rx for C-

• II opioids or

II opioids or hydrocodone/acetaminophen. hydrocodone/acetaminophen. y / p y / p

This includes patient or family member.

This includes patient or family member.

Photocopy ID or write down information.

Photocopy ID or write down information.

Photocopy ID or write down information.

Photocopy ID or write down information.

Reasonable substitute is ok if

Reasonable substitute is ok if circumstances warrant. circumstances warrant. circumstances warrant. circumstances warrant.

Generalization Generalization

Answers the question: “Do we agree on mutual

Answers the question: “Do we agree on mutual responsibilities and expectations?” responsibilities and expectations?” I am your pharmacist and I agree to promptly and I am your pharmacist and I agree to promptly and

I am your pharmacist and I agree to promptly and

I am your pharmacist and I agree to promptly and respectfully provide medications and services if rules respectfully provide medications and services if rules are met. are met.

Possible rules (but you decide what fits):

Possible rules (but you decide what fits):

Keep all controlled substances under lock & key.

Keep all controlled substances under lock & key.

No sharing drugs with anyone.

No sharing drugs with anyone.

If more than 20% too early, call prescriber.

If more than 20% too early, call prescriber.

Rxs for new drugs during prescriber business hours

Rxs for new drugs during prescriber business hours

Rxs for new drugs during prescriber business hours.

Rxs for new drugs during prescriber business hours.

No emergency “refills” when there is no emergency.

No emergency “refills” when there is no emergency.

It is your responsibility to know when you will run out.

It is your responsibility to know when you will run out.

Your choice, but use only one pharmacy for CS drugs.

Your choice, but use only one pharmacy for CS drugs.

Put this in writing if necessary.

Put this in writing if necessary.

Interpretation Interpretation Interpretation Interpretation

Answers the question: “Do I now feel comfortable

Answers the question: “Do I now feel comfortable s e s t e quest o

• ee co
• tab e

s e s t e quest o

• ee co
• tab e

allowing this person to have controlled substances?” allowing this person to have controlled substances?”

Contact another pharmacist for support with

Contact another pharmacist for support with “h h i l i ” N f “h h i l i ” N f “hypothetical question.” No names of anyone. “hypothetical question.” No names of anyone.

Use brief questionnaire to predict misuse or abuse by

Use brief questionnaire to predict misuse or abuse by patient (on Internet) patient (on Internet) patient (on Internet). patient (on Internet).

Opioid

Opioid Risk Tool (ORT) Risk Tool (ORT)

Screener and

Screener and Opioid Opioid Assessment for Patients in Pain Assessment for Patients in Pain p (SOAPP) (SOAPP)

Obtain family or friend participation and feedback

Obtain family or friend participation and feedback regarding success of therapy based on patient regarding success of therapy based on patient regarding success of therapy based on patient regarding success of therapy based on patient functioning. functioning.

Legalization Legalization Legalization Legalization

• Answers the question: “How can I stay squeaky

Answers the question: “How can I stay squeaky

• Answers the question: How can I stay squeaky

Answers the question: How can I stay squeaky clean in meeting my legal requirements?” clean in meeting my legal requirements?”

• Follow state and federal laws for CS, with NO

Follow state and federal laws for CS, with NO Follow state and federal laws for CS, with NO Follow state and federal laws for CS, with NO exceptions. exceptions.

• Conduct a medication history for all chronic pain

Conduct a medication history for all chronic pain y p y p patients. patients.

• Perform Drug Use Review for all opioid analgesic

Perform Drug Use Review for all opioid analgesic prescriptions. prescriptions.

• Provide patient education to all chronic pain

Provide patient education to all chronic pain patients. patients.

• Document what you have done

Document what you have done— —but with care. but with care.

Implementing VIGIL in Pharmacy Implementing VIGIL in Pharmacy Implementing VIGIL in Pharmacy Implementing VIGIL in Pharmacy

Goal: Build a bigger buffer between the Goal: Build a bigger buffer between the

• bviously legitimate patient who is being

appropriately managed and the obvious appropriately managed, and the obvious diverter/abuser who should be denied access to controlled substances access to controlled substances.

Classify Patients by Level of Risk and Care

L Ri k St d d C

Low Risk—Standard Care Medium Risk—Special Care

Hi h Ri k E C

High Risk—Extra Care

Negative Factors for Negative Factors for Classification Classification Classification Classification

Patient pays cash although covered by Medicaid.

N t L l R id t f C t

Not a Legal Resident of County. Unwilling to Accept Generic. Opioid, benzodiazepine, muscle relaxant. Patient subject of local “hotline” alert. Report of lost or stolen meds more than 1x in

past 6 mo.

More than 20% too early twice during past 6

mo. P i h b d i

Patient has been arrested in past year.

Positive Factors for Positive Factors for Classification Classification Classification Classification

Prescriber is Specialist/Known to Pharmacist. Non-problematic ePDMP report. Written Med Use Agreement w Prescriber &

Patient.

Rx for non-controlled substance w/in past 6 mo. Family Member/Friend willing to Accept

Responsibility.

Patient Under Care of Licensed Mental Health

Professional.

Managing Risk and Care Managing Risk and Care

Score

(Example)

Risk Care Level Approach

( p )

0-4 Low Standard Verify, ID 5-9 Mediu m Special Limited Days Supply (7, 14, 28) 10+ High Extra Medical g Records (HIPAA ( Release)

Hypothetical Patient A Hypothetical Patient A

Negative Factors (10 points)

Negative Factors (10 points)

Resident of another county.

Resident of another county.

Pays cash for $700.00 prescription.

Pays cash for $700.00 prescription.

Insists on brand name products.

Insists on brand name products.

Reported lost meds w/

Reported lost meds w/i i last 6 mo. last 6 mo. p / p /

Opioid

Opioid, , benzo benzo, muscle relaxant. , muscle relaxant.

Positive Factors (0 points off)

Positive Factors (0 points off)

Positive Factors (0 points off)

Positive Factors (0 points off)

None

None

Result: High Risk; Extra Care; Limit Result: High Risk; Extra Care; Limit

Result: High Risk; Extra Care; Limit

Result: High Risk; Extra Care; Limit Quantity & Review Med Records. Quantity & Review Med Records.

Hypothetical Patient B Hypothetical Patient B

Negative Factors (10 points)

Negative Factors (10 points)

Resident of another county.

Resident of another county.

Reported lost meds w/

Reported lost meds w/i i last 6 mo. last 6 mo.

Opioid

Opioid, , benzo benzo, muscle relaxant. , muscle relaxant.

Local hotline says “thus guy is dirty.”

Local hotline says “thus guy is dirty.”

More than 20% too early twice in past 6 mo.

More than 20% too early twice in past 6 mo. Positive Factors (8 points off) Positive Factors (8 points off)

Positive Factors (8 points off)

Positive Factors (8 points off)

Medicaid pays for meds.

Medicaid pays for meds.

Prescriber is specialist known to pharmacist.

Prescriber is specialist known to pharmacist.

Prescriber is specialist known to pharmacist.

Prescriber is specialist known to pharmacist.

Non

Non-

• problematic

problematic ePMP ePMP report. report.

Rx for non

Rx for non-

• CS w/

CS w/i i past 6 mo. past 6 mo.

Result: Low Risk. Standard Care. Verify Rx with

Result: Low Risk. Standard Care. Verify Rx with prescriber and require ID of person picking up meds. prescriber and require ID of person picking up meds.

References

• Brushwood, From confrontation to collaboration: Collegial

A bili A d h di l f h i i h

• Accountability And the expanding role of pharmacists in the
• management of chronic pain, J Law Med Ethics, 29: 69
• (2001).

Brushwood Pharmacist’s duty to dispense legally

• Brushwood, Pharmacist s duty to dispense legally
• prescribed & therapeutically appropriate Opioid analgesics,
• Pharmacy Times 68:55 (2002).
• Brushwood Maximizing the Value of Electronic Prescription
• Brushwood, Maximizing the Value of Electronic Prescription
• Monitoring Programs, J Law Med Ethics, 31: 41 (2003).
• Strickland, Huskey, Brushwood, Pharmacist-physician
• collaboration in Pain management practice. J Opioid Mgt 3:

g p p g

• 295 (2007).