Many nursing home patients and their loved ones may not be aware that as of 2 years ago DEA actions have resulted in a mandatory delay in carrying out doctors orders to treat pain or seizures.
The DEA has no mandate to ensure timely delivery of care in nursing homes, but they do have a mandate to combat the abuse of controlled prescription drugs. To that end, 2 years ago, the DEA suddenly decided that the existing processes of carrying out doctors' orders in Nursing homes did not comply with the DEA regulations. Since then the nursing homes and pharmacies working with nursing homes have had to deal with a restrictive bureaucratic process that has led to significant delay in care for end of life patients and patients suffering seizures.
In order to understand this complex process I will try to review the process of carrying out doctors orders for controlled substances (substances designated by the DEA as subject to abuse, i.e. Seizure meds like valium, narcotics, some hypnotics, etc.).
A.
The old process of carrying out orders before 2009 DEA actions:
1. An order by the doctor is written in a nursing home patient's chart in person or by telephone order to the nurse.
2. The doctor's order is faxed to the nursing home pharmacy.
3. In case of an emergency, i.e. Seizure, or pain or respiratory distress, the nurses had the option of using the "emergency box" in the nursing home to dispense the medicine. Pharmacy staff would later replace the dispensed medicine and document it's use.
4. The pharmacy would supply the nursing home with the medicine ordered, and in case of narcotics orders, they would also send a duplicate order to the doctor to sign within 7 days.
5. Checks and balances were in place to ensure that the doctor's order is documented in the nursing home charts and the pharmacy files and that these two records matched. The pharmacists did routine monitoring and reported any discrepancy in records or discrepancy in number of pills to the DEA and the police. This was done to combat a known problem of drug diversion (stealing) in the nursing homes.
B.
New process imposed by the DEA since 2009:
1. Doctors' orders for controlled drugs in nursing home charts in person or by telephone orders are deemed inadequate and can not be carried out by nursing staff even if the doctor is on sight.
2. All orders for controlled substances have to be coupled with a hard presiciption from the doctor, that can't be filled unless it's faxed and processed by the pharmacist. For a patient in seizure or in end of life distress that adds a time element to process this added bureaucratic paperwork. Nurses can not follow orders even if the doctor has given the order and is at bedside, unless and until the pharmacist processes the paperwork.
3. The "emergency box" in the nursing home can no longer be used by the nurses to carry out doctors' orders unless a pharmacist confirms the orders with the doctor on the phone in a separate call, or receive a faxed hard copy of the prescription. The copy of the doctor's order is no longer adequate.
Many geriatricians, including myself, have been trying for two years to seek support from congress to remedy this problem that's out of sight and out of mind for many Americans. I am sorry to say that aside from meetings with aids to our senators and congressmen, we have not achieved much in Maine.
Senators Whitehouse from RI and Senator Kyl from AZ have championed this cause but so far they have not been able to presuade the DEA to change it's stance, or to introduce meaningful legislation that takes into account the need to allow timely treatment for seizures and end of life distress. They also failed to presuade the DEA to stop looking at the doctors to police drug abuse by nursing home staff.
What's the solution?
1. State Attorney generals could consider taking the DEA to court to ensure that their citizens in nursing homes are not denied timely care due to federal regulations by the DEA.
2. Congress could dictate to the DEA that they can not place law enforcement ahead of patient care in nursing homes and should allow doctors and nurses to do their job in providing end of life care and seizure treatments in a timely manner.
3. Congress could dictate to the DEA that they should enforce existing (pre-2009) checks and balances instead of creating new regulations to deal with the long standing drug diversion issue in nursing homes and assisted livings.
4. Congress could mandate that the DEA should apply above standards to assisted livings with contracted, in-house, pharmacies, as many elderly receive care in such facilities and have similar needs as nursing homes.
Thank you for reading this post. Feel free to send me questions or comments.
Please feel free to read the petition (and sign it if you agree) originally posted in nov 2009 on this issue.
http://www.gopetition.com/petition/32305.html
Jabbar Fazeli, MD
Geriatrician
Current president of Maine Medical Directors Association
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