NADONA/LTC | National Association Directors of Nursing Administration
in Long Term Care

A Battle Against Prescription Drugs Causes Pain

A Battle Against Prescription Drugs Causes Pain

By JOHN LELAND
Published: October 2, 2010

It took two days to get the painkiller.

Mr. Lorenz, 75, lives in a nursing home in St. Louis. Until recently, the nurses would have sent an order to the pharmacy for the Percocet, based on instructions phoned in from the clinic — a longstanding practice for nursing homes, which typically do not have a full-time doctor on staff.

But now that practice has come under the scrutiny of the Drug Enforcement Administration. Last November, the pharmacy serving Mr. Lorenz’s nursing home announced that it would no longer dispense certain narcotics without a written or faxed prescription from a doctor.

For Mr. Lorenz, this meant a weekend of pain. The doctor at the pain clinic was not available, and the nursing home’s doctor on call would not write a prescription without examining Mr. Lorenz in person. For the next two days, Mr. Lorenz said, “I was miserable. I needed it to get straightened out. It was killing me.”

Staff members assured him that the drug was on its way at least six or seven times, said Mr. Lorenz, a former Marine and police officer.

“It’ll be there by midnight. It’ll be there by 2 a.m. The pharmacist kept saying he needed to talk to the doctor. It was real, real rough.”

Nursing homes and doctors say patients like Mr. Lorenz have become unintended casualties in the war on drugs because of a new level of enforcement intended to prevent narcotics from getting into the wrong hands. About 1.4 million Americans live in nursing homes.

The D.E.A. is investigating pharmacists in “about five states” for dispensing the drugs to nursing homes without direct written orders from a doctor, said Gary L. Boggs, an executive assistant in the agency’s Office of Diversion Control.

Earlier this year, the Senate’s Special Committee on Aging heard testimony from long-term-care professionals describing delays in delivering pain medications to patients. Two Democratic committee members, Senators Herb Kohl of Wisconsin and Sheldon Whitehouse of Rhode Island, have urged Attorney General Eric H. Holder Jr. to find a solution.

“We keep hearing the right things from the D.E.A. on this issue, but we haven’t seen any action,” Mr. Kohl said through an aide.

Mr. Boggs said the agency was just trying to protect patients. “This isn’t a matter of us being bureaucratic pencil pushers,” he said. “What we see is nurses unilaterally calling inprescriptions, or pharmacists dispensing controlled substances without a prescription, then trying to get a doctor to sign a prescription for a patient he never saw.”

In the meantime, doctors say, their patients suffer — sometimes for half an hour, sometimes for several days.

“There’s just a lot of potential for error in the process,” said Dr. Jonathan Musher, a geriatrician and past president of the American Medical Directors Association, a trade group of long-term-care doctors and administrators, which has sought a change in the requirements.

The problems are most common when patients first arrive at nursing homes fromhospitals, Dr. Musher said.

For example, he recently had a patient move to a nursing home after a hip fracture. At the time, she was not on narcotic pain medication. That night the nurse called Dr. Musher to say that the woman was in pain. “I was told I had to call the pharmacist,” he said. “O.K., what’s the pharmacist’s number? The nurse has to call me back, she wasn’t sure. I get a call back with the number. I call the 800 number and leave a message. I get a call back a half hour later.

“So now there’s been a 45-minute delay. Now he tells me I have to fax in a prescription. I’m not home, so I say I will do it in 15 minutes. After I fax it, I call the nursing home, and they haven’t heard anything from the pharmacist. Finally I told them to send the patient to the hospital.”

She got her medication, “but that’s something we don’t want to do,” Dr. Musher said. “There are health issues with transfer, as well as the costs of transfer.”

Critics of the nursing home industry say the bigger problem is that facilities are not providing adequate medical care to their patients.

“If people are so sick that they desperately need pain medication, they should be seen by a doctor,” said Toby S. Edelman, a senior policy lawyer at the Center for Medicare Advocacy, a nonprofit law firm that provides legal assistance to Medicare beneficiaries. “The absence of doctors in nursing homes has been a problem for decades, and this doesn’t solve it at all.”

According to the medical directors association, a doctor at a nursing home writes an average of 169 prescriptions for controlled substances each month — which means ample opportunities for delays, Dr. Musher said.

Dr. Cheryl Phillips, president of the American Geriatrics Society, said that such delays were “daily” occurrences, especially in rural areas, where doctors might need to travel long distances to reach their fax machines or might not be able to send prescriptions by smart phone.

“I respect the work the D.E.A. is doing to prevent diversion of drugs” for sale or recreational use, Dr. Phillips said. “But the law does not serve seniors well.”

The solution, she said, “is to have the nurse act as agent to the physician,” taking the order and administering it then and there, “the way they do in a hospital.”

The change has put more pressure on nurses, who may have a suffering patient and a doctor’s order but are unable to dispense the painkillers, said Lynda Goldthwaite, aregistered nurse and administrator at Elmwood Skilled Nursing and Rehabilitation Center in Claremont, N.H.

On occasion, she said, she has told nurses to go ahead and administer drugs from the center’s emergency kit without waiting for authorization from the pharmacist. “That’s a big no-no,” she said. “I could be in big trouble with the D.E.A. But I do it anyway.”

She added: “I’m a nurse. I know what I have to do for my patient.”

Mr. Lorenz said the Percocet has helped him live with his pain. But he is still angry about having had to wait for days. “I’m too old to be aggravated,” he said, adding, “I’m a victim of bureaucracy.”