CEimpact Podcast

Opioid Use in Palliative and End-of-Life Care

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Opioids remain a cornerstone of palliative care for patients with serious illnesses like cancer, yet their use is often misunderstood, undertreated, or approached with unnecessary hesitation. This episode explores what pharmacists need to know about assessing opioid appropriateness, questioning therapy when warranted, and supporting comfort-focused care within established clinical and ethical standards. Tune in to build confidence in your role and contribute meaningfully to the care of patients facing serious illness.

HOST
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact

GUEST
Lorin Fisher, PharmD, BCACP
Clinical Assistant Professor
University of Iowa College of Pharmacy

Joshua Davis Kinsey and Lorin Fisher have no relevant financial relationships to disclose.

CPE REDEMPTION
This course is accredited for continuing pharmacy education! Click the link below that applies to you to take the exam and evaluation:


CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Identify the role of opioids in managing pain and other symptoms for patients receiving palliative care.
2. Describe key considerations for evaluating opioid prescriptions in the context of serious illness, including appropriate use and safety concerns.

0.05 CEU/0.5 Hr
UAN: 0107-0000-25-330-H01-P
Initial release date: 11/10/2025
Expiration date: 11/10/2026
Additional CPE details can be found here.

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SPEAKER_00:

Hey CE Impact subscribers, welcome to the Game Changers Clinical Conversations Podcast. I'm your host, Josh Kinsey, and as always, I'm excited about our conversation today. When a patient is facing a serious illness, managing pain and other symptoms becomes a central part of care. And opioids often play a key role in that process. In today's episode, we'll explore how pharmacists can support appropriate, compassionate opioid use while navigating the clinical, ethical, and regulatory complexities of palliative and end-of-care, end-of-life care. And we are so pleased to have joining our episode for today, Lauren Fisher. Lauren, it's your at least second time with me, I think, coming back. So welcome back to the podcast. For our listeners that may not have heard your previous episode, go ahead and take a couple of minutes to introduce yourself. Tell us a little bit about your practice background, your practice setting currently. And I know that this topic is kind of passionate for you. So tell us a little bit how you got into this space.

SPEAKER_02:

Yeah, thanks so much, Josh. I'm glad to be back. So my name is Lauren Fisher. I'm a clinical assistant professor at the University of Iowa College of Pharmacy in Iowa City. My clinical practice site is right across the street from the college at UI Healthcare's main campus and our supportive impallive care clinic. Our supportive impallific care clinic sees patients with a variety of different types of serious illness. About 80% of the patients that we see are living with some type of cancer. But we also see patients with end-stage liver disease, renal disease, advanced cardiovascular conditions, advanced neurologic conditions as well. We do symptom management for those serious illness. So pain management is a big component of that, and obviously our topic for today. But we also facilitate conversations about what's most important to patients in the context of living with a serious illness as well. My previous podcast that I was a part of, we had conversations about aligning medications and providing meaning to medication management. So for those who are interested, I encourage you to take a look at that previous podcast.

SPEAKER_00:

Yeah, thanks for that plug. Please do.

SPEAKER_02:

Yeah, but yes, this is something I'm I'm very passionate about. I've done some research in this area of exploring what types of barriers that patients may have access to, to opioids that may be prescribed in the context of living with a serious illness, because there certainly are considerations about using opioids for this niche patient population that are sometimes inappropriately prescribed as it relates, or inappropriately considered rather, as it relates to regulatory standards, legal standards, and other considerations, which I'm sure we'll talk more about today.

SPEAKER_00:

Yeah, yeah. Well, thanks again, Lauren. It's always a pleasure to have you. I know we've interacted in other projects and courses before, but you know, this being the second episode, I'm just I'm grateful that you've given us more of your time. So thanks again. So let's jump into today's topic. As Lauren mentioned, we're gonna be, and as I mentioned earlier, we're gonna be talking a little bit about opioid use in patients for palliative care. And so just let's kind of set the stage. Listeners have learned that one of the things I like to do first is just kind of lay the groundwork, make sure everybody's on the same page. So let's just talk about just a quick overview, if you will, of opioid use in palliative care. What are we focused on? What are the kind of the overall goals of using opioids in the palliative care space?

SPEAKER_02:

Sure. So I think it's important to recognize that for any type of disease state, whether an individual is receiving palliative type care or not, that opioids are not disease-modifying medications. Really, what they do is they interfere with the central processing of pain. And so it's important to take that into consideration that the underlying cause of the pain, opioids are not addressing that. So we always want to make sure that we have an understanding of what is causing the pain and that we're addressing that appropriately in alignment of what patients' goals are. There are a number of guidelines out there that outline appropriate opioid prescribing practices. Um, probably the most noteworthy are the CDC guidelines for opioid prescribing. Individuals that are receiving palliative care, end-of-life care, or are living with sickle cell disease are actually exempt from these guidelines. And these guidelines are often kind of the source that drives the creation of institutional protocols, state protocols, and third-party protocols as it relates to opioid prescription considerations.

SPEAKER_00:

Okay, great. And that is how often do those guidelines change? Like how often are they updated?

SPEAKER_02:

Oh, geez, the last set of guidelines I believe came out in about 2022, 2023. And prior to that, they were out in 2016. So was recently revised in the past two to three years.

SPEAKER_00:

Yeah. And I I say that just because I think it's important for learners to understand because some guidelines are updated every year. And you know, it's always important to stay up to date on diabetes guidelines because they always come out every January, you know, whatever. So it's important just to kind of have a better understanding of when the guidelines are coming out, just so you can stay up to date. So I want to go back. I heard you say that two sets of individuals are exempt from those guidelines. What it what exactly does that mean? Like when you say that, what does that mean?

SPEAKER_02:

Sure. So essentially the guidelines are not applicable to those patient populations. And so it is important to consider that what you read in those guidelines, while they are important considerations for opioid stewardship, that those parameters of opioid stewardship, if being applied to any type of like institutional protocol or like a legal sense, that patients that are receiving end of life or palliative care, or if they're living with sickle cell disease, that those parameters of the guidelines should not apply to those patient populations.

SPEAKER_00:

And is that typically because we're potentially a little more aggressive with the pain management and the dosing for those patient populations?

SPEAKER_02:

Yeah, really great question. So, really, when we think about pain managers, it is important to think holistically of analgesics and what may be appropriate for a given patient situation, other comorbidities that they may have, organ function, but also what is the underlying painful condition that we are treating. And so oftentimes in the setting of end-of-life palliative care, oftentimes that is cancer-related pain. And opioids have been shown to be more beneficial than other types of analgesics. And same is true for sickle cell disease. So so to speak, the the risk-benefit profile may be a bit more favored for those patient populations. Um, that being said, I you may think, should we be thinking about opioids as like first line for these patient populations? Again, I like to think holistically and think, can we utilize other analgesic modalities first if we can? But if pain is so severe or if there are considerations that would prevent the use of other analgesics, such as cardiovascular disease, cardiovascular disease, reduced renal function, or hepatic or liver infection, liver function, then obviously I may revert to thinking about an opioid first instead of as a second option.

SPEAKER_00:

Sure, sure. And I actually have this later in in my notes, but I feel like I I should have moved it up and I kind of want to talk about it real quick because we mentioned both a few times. Can we define palliative care versus end-of-life care? Like, is there a difference? Are they used interchangeably? Like, let's go ahead and maybe I feel like that might be necessary foundational information.

SPEAKER_02:

Yeah, I'm glad you brought that up first because it is very um very foundational information. So palliative care is what I like to call and what many of my colleagues and guidelines like to call is providing an extra layer of support for a patient living with any type of serious illness. So I mentioned the types of patients that I see in my clinical practice is really vast. And so we provide care for patients living with any types of type of serious illness, and then they can be at any stage of their disease trajectory. So meaning we may see them the time following a diagnosis of a serious illness, or we may see them later on in their disease trajectory as complications exist, as a severity of symptoms may progress more, or if patients just request it. So we kind of see the gamut of where patients may present in the setting of a serious illness. Hospice, on the other hand, which sometimes is viewed as a synonymous or interchangeable term with palliative care, is a medical definition in which a provider would not be surprised if an individual would die in the next six months. So it does have that six-month diagnostic or a prognostic indicator. But in my clinical practice, we see patients regardless of their prognosis. We help facilitate referrals to hospice if and when it's appropriate. We facilitate conversations about what hospice is and what patients' viewpoints are about hospice. But this is an important conversation that I like to facilitate with patients and their loved ones when we see them in clinical practice, because sometimes that is the elephant in the room of what the difference between palliative and end-of-life care or hospice care is. Because with what is out there in the literature, what's out there in the media, it can be really confusing to tease through.

SPEAKER_00:

Yeah, for sure. So it sounds like, I mean, while I guess they could be used interchangeably, we just need to understand that some patients who are receiving palliative care may not be in that end stage prognosis. Like they may not have, you know, they may live for 10 more years or whatever. Exactly. Right. Yep. Okay. Okay, that's good to kind of clear up. And I think it's important just to note that when we say those, again, end of life care could be receiving palliative care, but just because you're receiving palliative care does not mean you're in end of life, I guess.

SPEAKER_02:

Right. And to kind of then segue into what we were talking about before as it relates to selecting opioids is if we suspect that a patient may have a prognosis of many years, we may be more worried about chronic adverse effects of opioids that may precipitate after they've been taking it for several months or even years. So concerns about hyperalgae, impact on endocrine function, impact on bone health. Those are some of the things that we do worry about for patients that we may see in disease survivorship or may have been living with a long-standing serious illness in which they've been prescribed opioids. So my clinical thought process of thinking about whether opioids may or may not be appropriate or what dose is often interrelated to disease prognosis as well.

SPEAKER_00:

Yeah, that makes sense because, like you said, if if they have many, many years, you know, expected left to live, then why jump straight to opioids if if it's gonna cause more problems down the road? So yeah. Okay, that's great. Okay, so I think we'd be remiss if we didn't talk about just kind of the public health context of opioid use and also just in general that there is a a I guess a misunderstanding or a stigma or fear associated with using opioids or prescribing them or you know, things like that. So let's kind of touch on those for just a little bit. So let's start with kind of that misunderstanding of opioids. If you can kind of, I don't know. I don't know if I've set you up well with a question there. No, that's all right. Okay.

SPEAKER_02:

I think that just in the world what we we live in with the publicity of the opioid epidemic, that has created a sense of sphere, so to speak, among many individuals, particularly pharmacists. Um, you know, the Controlled Substance Act says that we have a corresponding responsibility of providers to ensure that we are recognizing that this is an appropriate prescription, appropriate dose, appropriate indication. And opioids really kind of drive home that point. And so it is a core part of a pharmacist's job to have this level of stewardship for any medication, but with the considerations with the opioid epidemic and and of the media that can evoke that sense of fear. Um, providers also have a similar sense of fear from a prescription perspective as well, of thinking, is this an appropriate indication for prescribing opioids? And particularly, this is can be a really great opportunity for engaging pharmacists in the ambulatory care setting or the acute care setting if you're facilitating a hospital discharge, for example, to determine if as it relates to that corresponding responsibility, working right there with the provider, if this is an appropriate indication, dosing's appropriate, et cetera. And then understandably, patients, when they hear the word opioid, it may cause their eyebrows to raise a little bit, particularly causing calling out particular opioids as well, morphine, eventanil, those are could be some concerning medications for patients and sometimes fears that we need to learn a little bit more about in clinical practice. So I encourage pharmacists and providers in general, if they can pick up on some of those nonverbal cues of patients seeming a little bit concerned about a particular opioid or just hearing the word opioid, that particularly in the patient population we're talking about today, that we are providing reassurance that these medications are being used for a legitimate medical purpose. And that concerns surrounding things like addiction, tolerance, and dependence are things that we assess regularly as pharmacists, as regardless of clinical practice setting and as providers. And those three terms that I used addiction, tolerance, and dependence, like sometimes that can be like a good thing to define to patients because there is there is a difference, and sometimes those things are those terms are used interchangeably.

SPEAKER_00:

Yeah. And I think it's important, you know, to not be dismissive of patients' fears or concerns because it's real. I mean, just my sister just underwent a pretty major surgery. She had a kidney removed, and and she, you know, texted me and was like, I'm I'm having to take my opioid p pill twice a day. Is that okay? And I'm like, sis, you just had a kidney removed.

SPEAKER_02:

Yeah.

SPEAKER_00:

I think that's okay for a while. Like, you know, we're not taught you. She's like, I just don't want to become addicted or I don't want to become dependent upon it or whatever. And I'm like, you know, so I think it that that fear is real in patients. Like they really do, they hear it in the media, they hear it, you know, the the concerns or the the the trouble surrounding, you know, the opioid epidemic. So I think it's important for pharmacists to to not be dismissive, but like you said, take that opportunity to define, to further talk, and to further have the discussion so that the patient is well informed and understands exactly, you know, what's going on with their care at the moment. So yeah.

SPEAKER_02:

And I think to to build upon that just a little bit further is to define what is realistic pain expectation. So, you know, you gave the example with your sister following a surgery, pain may improve in the coming days to weeks. But if we have a patient living with an inoperable tumor, that may be something that may be persisting for the rest of their life. And is that a sense of permission to use a medication like an opioid, for example, to help them do their activities of daily living, do the things in life that matter most to them. But then also on the flip side of educating if some degree of pain is going to be something that they're going to potentially live with for months, years, or indefinitely, um, what's realistic for pain? Our goal is always to improve function, to enhance quality of life. But that goal may not be to get pain down to an absolute zero. And so that is another good point for pharmacists, regardless of their practice setting, is to explore with patients what their understanding of their pain goals are. Um it could be a point of pharmacists to educate, educate about what is realistic expectation, or it can be a point for a pharmacist to be an advocate for the patient to follow up with a provider to say, you know, what is reasonable.

SPEAKER_00:

I love that. Yeah, yeah. So not only reviewing expectations, but sometimes setting them and helping to collaborate to set them. So yeah, that's great.

SPEAKER_02:

And the earlier you do that, the more successful sometimes long-term outcomes can be.

SPEAKER_00:

Oh, for sure. Because it it's almost like getting everybody on the same page before you start writing it. So yeah, for sure. So we've kind of touched on the role of the pharmacist in this space. And, you know, obviously we're we're there for safe and appropriate use of all medications, specifically in this instance. Um, and I and it's, you know, I I want to be sure that we're also not being dismissive, that it's okay for you as a pharmacist to have a little concern or fear when you see an opioid prescription come across, you know, for for your approval or whatever. So it's okay to have that. And it's okay to take a second look and to pause and to double check and whatever. Um, but one thing that I wanted to talk about was well, and actually I'm gonna get to it later. So I want to say that, but I I do want to bring in patients and and because sometimes who's involved are their families or their caregivers. So I want to be sure that we spend time on that. But I do have another point on that. So let's jump into, we've touched on this a little bit, but let's reiterate what are those appropriate indications for using opioids in the palliative care setting? And, you know, as you mentioned, it it differs for patients, and so we're gonna have to start asking questions and it's also gonna be layered. But then I guess how do we determine if if some of these are exempt from some of those guidelines, how do we determine dosing and how do we determine first line? And you know, do you jump right to a fentanyl patch or do you try a five milligram oxycodone first? Or, you know, like what what are the how do we do that if we're not if we don't really have the guidelines to go off of, I guess, if that's what I'm saying. Misrepresenting that.

SPEAKER_02:

So make makes sense, lots to unpack there, but I think just generally speaking, is that analgesic regimens, including opioids, really need to be individualized as much as possible according to patient-specific factors. What is challenging, especially for our pharmacists practicing in the community space, is that there is missing information to help determine appropriateness of indication and dosing. So, yes, if you see a prescription for a transdermal fentanyl patch come across for a patient, that you've checked the prescription drug monitoring program, you've checked previous prescriptions, and you don't see any indication that the patient has been on opioids historically, yeah, that should definitely kind of raise an alert in your mind and want to ask further questions. Um, but I would definitely encourage, particularly pharmacists that are being available at the point of prescribing with providers to help put in information to help our community pharmacists as as they facilitate that care transition. So making sure that there are diagnosis codes on prescriptions. In Iowa, you don't have to have a diagnosis code on a prescription, believe it or not. Um, so that is something I would strongly encourage providers to have.

SPEAKER_00:

I think that's true in a lot of states. Yeah. I mean, I don't think that many of them require it. So yeah, that's a great point, though. I love that that making sure that they're on there, especially if you're a pharmacist in another setting. Yeah. Because that could translate to easier discernment from community pharmacists. Yeah.

SPEAKER_02:

So for example, like for our patients that are living with cancer-related pain in my clinical practice, I always make sure that there is cancer-related pain as a diagnosis code. And then followed by palliative care is also a diagnosis code. So I always make sure there's two diagnosis codes on the prescription. And then if there's any information that's like relevant to pass off that you think that a provider may not, or excuse me, rather, a pharmacist may not have by doing a prescription drug monitoring check. Um, oftentimes a lot of electronic prescribing systems have opportunity to put like notes in a prescription. And so having that extra note, you know, can save a phone call, which may be hours on the phone, maybe even more than hours, continuing to the next day, delaying care to patients, or being proactive contacting the pharmacist at the dispensing pharmacy, faxing information if applicable. Um, but in absence of that information, I just really encourage community pharmacists. I recognize that there's so much that impacts their busy day, to take a moment and pause and ask patients openly, tell me a little bit about what this medication's prescribed for you for. We use it for lots of different things, but could you tell me a little bit about it? And you know, that kind of gets to the underlying premise of that pharmacists have a corresponding responsibility. And if you ask with a sense of openness and humanness really and clinical curiosity and concern, yeah, that patients may be willing to open up with you and and share what's going on rather of it coming across as being somewhat of a punitive, record-keeping hypothetically. Yes.

SPEAKER_00:

Yeah, yeah. No, that's a great point. I love also the fact that you that you're basically advocating and and and encouraging other pharmacists to support other pharmacists because we you know, that's one of the beauties of our profession is that we can work in 4,000 different settings. And but being able to identify and recognize that, hey, this this might be a point of issue or a pain point or barrier for another pharmacist down the road who's filling this or dispensing this to the patient. Um, so I love that idea of making sure that you are being complete with putting the diagnosis codes on there, adding some notes, touching base with them if you feel the need to. So that's really good advice.

SPEAKER_02:

Yeah. Because again, use oh, go, sorry, go ahead.

SPEAKER_00:

I was just gonna say, because again, that you know, the dispensing pharmacist ultimately is the one that is making that final decision. So any information that can be shared with them is is helpful. So yeah, that's a great point.

SPEAKER_02:

So I mean, I'll give a perfect example. So I use that transdermal fentanyl prescription that may come through to a community pharmacist. If there is an opportunity to put a note in the prescription that the patient has been admitted in the hospital for the last 10 days and they've been taking 60 oral morphine equivalents for the last seven days, which is the requirement for starting a transdermal fentanyl patch, you know, that is kind of you know the click in the verifying pharmacist's mind to be like, okay, then this is appropriate indication and it saves a phone call.

SPEAKER_00:

Yeah, no, it's great. I love I love pointing that out. That's that's really good. So I think we did this before. I had this is where I had my note to just to distinguish between palliative care versus end-of-life care. So I'm glad we did that earlier. I think that set the stage really well. Here's where I want to get into patients and caregivers, because I feel like oftentimes it may be our patients, as you mentioned earlier when we were talking before we started recording, you know, some of these patients who are receiving this care from us may not be the best point of giving historical relevance or something like that. So there may be a caregiver involved. What sort of level of complexity does that add to the mix when we're taking care of these patients?

SPEAKER_02:

Yeah, that's a really great point because we definitely want to appreciate patient autonomy as much as possible, but recognize that there could be a number of different factors that are interfering with that. And so if a patient does have a trusted caregiver that is a part of their at-home care team, that's a really huge asset for their care. So one thing that like I may be providing particular education to caregivers about, and my role again is an ambulatory care, but I think that pharmacists, regardless, regardless of their care setting, can do this, is to encourage patients and caregivers to keep a log of how frequently they may be taking as needed opioid medications. Um that's important for us calculating daily oral morphine equivalents and helping with us facilitating safe dose adjustments. And so whether it's an app in your phone, whether it is a notebook jotting things down, I would encourage both patients and caregivers to take an active role in doing that of recording when PRN doses are given. Because that can help us adjust both short-acting or PRN doses, but then also the consideration of starting a long-acting opioid as well and adjusting the dose of long-acting opioids. So that would be a consideration.

SPEAKER_00:

Yeah. And in addition to, you know, it being at the ambulatory ambulatory care meeting or you know, appointment that you're mentioning that that's when you encourage it, the dispensing pharmacist could also encourage that as well because close that loop. So it's, you know, that's more of it, that's a task that others could take on as well. So yeah.

SPEAKER_02:

Yeah, absolutely. I think the other piece is from the perspective of kind of like a public health opioid safety consideration, is that when we dispense opioids to patients or prescribe opioids to patients, you know, there's always a concern that they may get in the hands of someone that does not have a legitimate medical purpose for them as well, or, you know, an accidental situation that may have terrible consequences. So in my clinical practice, we dispense naloxone for every patient in which we are, I should say we rather we prescribe naloxone for every patient in which we send an opioid prescription, regardless of whatever their dose is, just because of, as I mentioned, the public health and the safety considerations, not just for the patient, but for others in the home. And that's for patients at any stage of a serious illness, even towards end-of-life considerations as well. So making sure that caregivers know how to use naloxone because it would not be something that a patient would administer to themselves. Many states, and I actually think almost all states have a standing order regarding naloxone dispensing. And so even in absence of a prescription, naloxone can be dispensed to a patient. So if you are in the community pharmacy setting and you're involved with community pharmacy protocols, maybe developing a protocol of thinking about when you would want to dispense naloxone to a patient, if it is a certain diagnosis code, if it's a certain opioid dose. So then that is just something that is routine in your clinical practice instead of awaiting for a patient to request it, because it there's a possibility that they may not be aware of what naloxone is or what an individual patient's risk is for opioid overdose or respiratory depression.

SPEAKER_00:

That's a really good call, Lauren. I appreciate you bringing that up. I feel like that was even missed in my initial notes, but I think that analoxone should be in the in the midst of a conversation anytime opioids are in the midst of a conversation. So you know, recently talking with a a colleague that did another course for us, and she was very proactive and set up a system, a workflow kind of interplayed with their workflow. Uh, when a prescription was being dispensed, an opioid prescription was being dispensed, it flagged the one of the pharmacists to an immediately have the conversations about naloxone. And so they were able, it was ridiculous numbers, like so good as far as like getting more of the naloxone doses into the right hands. So and I think she even had a data on save, you know, lives basically, because like actual use of naloxone and how the fact that they got it into the right hands. And so, yes, great point. Thanks for bringing that up. I think it's really important that that is a conversation that's had any time that opioids are being dispensed. So okay, so let's talk a little bit about we we touched on this too as well, but just to kind of reiterate one of the other opportunities for pharmacists is to be sure that we're collaborating with the other members of the healthcare team, um, specifically with the per prescribers. And as you mentioned, making sure that prescriptions are have the diagnosis codes, making sure that notes are going there that's a that are appropriate. And if you're in the dispensing side, then you know, if you don't have the luxury of someone giving you those notes or that heads up, it could be the case that a phone call is necessary or you know, just a quick touch base with the prescriber to make sure I think that that can often clear up some confusion.

unknown:

Yeah.

SPEAKER_00:

And as you mentioned too, talking with the patient directly, like that can also clear up confusion.

SPEAKER_02:

So I'll just add checking the prescription drug monitoring program for your state and a neighboring state is also really, really important to gather relevant background information, regardless of your clinical practice setting as a pharmacist.

SPEAKER_00:

Yes. And I think, you know, I love that point as well, like thinking about if you think oftentimes patients who are who have cancer, they may be seeking treatment from another state. It could be that they're going to a specialist that's somewhere else. So I think that's something really important to note as well. That, and again, that's where proper communication with the patient could bring that up and say, oh, well, I've been staying in X state for six months, and that's where I was treated with this. So this is now the next move. I'm finally back home or whatever. So yeah, great, great point. All right, so some of the challenges we touched on these, but just briefly reiterating them there is a stigma and some fear surrounding opioid use, not only with dispensing it, not only with prescribing it, but also from the patient perspective of you know, accepting it and taking it. Um, and I think we we touched on well kind of how to communicate and to properly overcome that fear and how to address the questions and the concerns that patients may have. And then I think we touched on assessing some prescriptions that appear higher and usual without undermining care goals. So that's that's a role that we have to do. And we talked about that asking the right questions, talking with the patients, picking up the phone if necessary, and speaking with a prescriber. And then is there any other anything else from a compliance or regulatory perspective that you want to bring in when when dealing with open prescriptions?

SPEAKER_02:

Yeah, so one piece that I'll add from the perspective of you know, you're doing your best. To reach out to a provider and collaborate, and you know, you're not able to get a hold of them and the patient's waiting in your pharmacy, what do you do? Many states have laws about doing partial fills of opioids. So thinking about, you know, is there a possibility that I can do a partial fill of this prescription until I get a little bit more information, recognizing that if I prevent the patient from getting access to this necessary medication, that this may create some undue suffering. Um, but then it also allows for a sense of safety for me to gather more information before dispensing the rest. So that would be something I would encourage you to think about and even to think about like developing community pharmacy policies surrounding yes, yes. Um, so that's an important consideration.

SPEAKER_00:

I think that's great. And I I I would encourage everyone, you know, if you're unsure of what your state laws are about that, to to check with your board of pharmacy and see what those are. But that's a very, very great point. Thank you.

SPEAKER_02:

Yeah, absolutely. And then also I've learned that like different states have different laws as it relates to dispensing day supplies of opioids. Sometimes I've noticed this as being like an insurance or third-party limitation that they may not allow for initial fill more than seven days, whether it's a short-acting or long-acting opioid. Some stores have policies of that. And then even some states have policies of that as well. So recognizing, you know, what may be some situations where the seven-day supply rule should not apply, like if there's a specific diagnosis code, for example. And so, and if that is above the level of like your individual pharmacy, advocating at a corporate level or even at a state level for opportunities for exceptions to those rules.

SPEAKER_00:

Yeah, that's great. Great, all great points. And I think all good things for pharmacists in in multiple practice settings to think about because I think a lot of those, it's not just in the dispensing and the and it's not just in the prescribing. There's other places where pharmacists are interacting with patients and can um note these changes or be advocates on the patient's behalf. So those are all great points. Great discussion, Lauren. This has been so helpful. And I feel like it even clears up some of the confusion that I think everyone has. I know I can speak for sure that I have on palliative care versus end of end of life care and and when do we start opioids? Do we jump right to them? You know, what to expect when you're seeing those come across in the dispensing form. So really good stuff. Is there anything that you feel like you wanted to add that we haven't touched on?

SPEAKER_02:

I have a couple of resources. Did you want me to share those now? So for anyone who may have questions about opioid calculations, which I mean that could be a whole podcast in and of itself.

SPEAKER_00:

That could be a three-hour podcast. Absolutely.

SPEAKER_02:

I would encourage you to check out the book Demystifying Opioid Calculations by Dr. Lynn McPherson. She's a pharmacist, a hospice pharmacist from the University of Maryland. She kind of is the expert in this area. So I would encourage you to check out her book. There's excerpts of it online that you can get for free. But if you want the full book, um, you can either purchase that through ASHP or ACCP. The other consideration is there is a free palliative care kind of resource, I should say, repository. It's called the Fast Facts through Palliative Care Network of Wisconsin. They have what really are. They're called Fast Facts, and there are hundreds of them, and they are concise, practical, peer-reviewed summaries ranging of things about things from symptom, pain, medication management, deprescribing, goals of care conversations, end-of-life considerations. So I'd encourage you to bookmark that as that can be really helpful to get some necessary background information that's also free as well.

SPEAKER_00:

Yeah, that's great. Very good. Thank you for sharing those. So one thing that I'd like to do before I wrap up each each episode is the name of our podcast, it's Game Changer. So, Lauren, what is the game changer here? What do you feel like is is the big take home that we want our listeners to go away with today?

SPEAKER_02:

Yeah, absolutely. I think wherever you can facilitate care transitions about opioids, really do your best to communicate that, whether that's through diagnosis codes, whether that's collaborating with a pharmacist in another care setting, whether that's providing education to a provider about what could be something that community pharmacist calls back and has a question about. Really do your best to think proactively about providing care transitions and recognize where there may be data that's missing that can impact the ability for a patient to access their needed opioid medication.

SPEAKER_00:

Yeah, that's great. And because it's not all about, you know, we think about, well, that's holding up us dispensing it or that's holding up whatever, but ultimately it's holding up the patient getting the medication that was intended for them and that they need, and that could change, you know, like you said, activities and and quality of life and whatnot. So and cause undue undue pain and harm. So yeah, so I think that's great point, really, really great point. Lots of nuggets from today, but I think that that is one of my favorites in the sense of think about ways in which basically your job could be easier and then advocate for those changes. I mean, that's that's really what it is. So and and ultimately it will help the patient get the care and and medication that they need. So well, Lauren, thank you so much. As always, it's a pleasure and really appreciate giving us your time today for today's episode.

SPEAKER_02:

Yeah, thank you so much for having me, Josh.

SPEAKER_00:

Of course. If you're a CE plan subscriber, be sure to claim your CE credit for this episode of Game Changers by logging in at CEimpact.com. And as always, have a great week and keep learning. I can't wait to dig into another game changing topic with you all next week.