Are Recommendations Infringing Upon Practice Autonomy?

Multidisciplinary panel of clinicians discuss whether recommendations made by national, state, and local agencies infringes upon clinical practice autonomy. 

Peter Salgo, MD: I can hear some physicians saying, “You are infringing on my right to practice the way I want to practice. You are going to make me give out naloxone. You are going to make me counsel my patients. You are labeling these drugs in a way that I do not think is appropriate for my patients.” I’m sure there are providers that say, “I want my autonomy here.”

Charles Argoff, MD: Can you name 1 doctor who would say it is not a good idea to educate a diabetic about hypoglycemia?

Peter Salgo, MD: No one who is not in prison at the moment.

Charles Argoff, MD: Exactly. It goes back to understanding what is normal and what is good medical care, emphasizing that good medical care means looking at the risks involved in any treatment: the good, the bad, and the ugly. The ugly is not breathing anymore and dying, whether it is intentional or unintentional. When we prescribe opioids with the best of intentions, to people who we have done very well, there still is a risk. That risk can be somewhat mitigated by the appropriate discussions and the appropriate use of naloxone. Hopefully, that that would resonate with more people. They can appreciate that this is the best practice, as they would do in their other areas of medical care.

Peter Salgo, MD: What are some strategies here? In other words, we agree. I suspect if you put this in the abstract, all physicians would agree that living is better than dying. Overdoses are bad; naloxone prevents them. How do you get from here to getting physicians onboard and saying everybody should be doing this?

Jeffrey Bratberg, PharmD, FAPhA: You have to change policy; that is the first step. Then you prescribe often. You get over your reluctance to do it, and there will still be physicians who will be reluctant, but I am sure you all know somebody who has gotten the call that said, “I’m so happy I had that naloxone, it saved my life.” Or someone may say, “I feel more secure that I have that.” These are the things happening in our state.

Joshua Lynch, DO, EMT-P, FAAEM, FACEP: It is a combination of carrots and sticks. It takes a policy to hit a certain group of folks. It comes with the reward of lowering the bar and making it easy. Or if you back up even further, we need to make folks think that this is both a good idea and with the policy, that it is required. Letting folks know that this is a good thing, making it easy, eliminating the need for a prescription when you can, and then having some antidote data to explain why it’s a good idea will all result in success.

We did a naloxone training a few years ago at 1 of the hospitals that I work at, and that night 1 of the nurses who works at the hospital saved her daughter. It does not take many cases like that to get a small microcluster of folks onboard very quickly.

It is not 1 effort that will hit everyone. Some physicians need sticks to get them moving in the right direction—maybe a lot of them do—but a mix between positive and negative reinforcement in addition to other stories that pull at folks’ heartstrings a little—a combination of all those things is the most effective.

Charles Argoff, MD: I also think that education starts early in our careers. If we can start educating the health care professionals in the beginning of their training, so it becomes integral to what they do, it will also help, because they’ll be coming out of their schooling with it being normal for them to do this.

Jeffrey Bratberg, PharmD, FAPhA: One of the things that we have done is we have pharmacies that have overdose response protocols. We think there is an overdose in a pharmacy once every single day. I know many of my colleagues and students have saved people in the parking lot and in the bathrooms, just as some have said. I just heard this week that we have lots of overdoses in Rhode Island. We were in the top 10 areas for many years. We are probably going to be in it this year. But at 1 of the major hospitals’ associated primary care clinics, someone overdosed and there was no naloxone, and none of the physicians or nurses or pharmacists carried it. They had to call EMS [emergency medical services] to their primary care clinic. I ask you, do all of you have naloxone, and is all your staff trained to use it? Dr Jeremy Adler is. nodding yes. It’s interesting: They said we’ve got risk assessment and legal involvement. I’m like, this is a no-brainer. All of you are health professionals. You should have had it. My student was walking past a hospital and saw someone having an overdose and a nurse who was walking at the same time, had naloxone, saved the person, got them connected to care.

Theresa Mallick-Searle, MS, RN-BC, ANP-BC: It’s the same sort of public health initiative as CPR [cardiopulmonary resuscitation]. It is going to take more, unfortunately. People do not like to be told what to do at any level, and this needs to be a mandate. We need to work together. I’ve seen the biggest push in terms of the promotion of naloxone for patient safety recently. I’m learning about what these EDs [emergency departments] are doing, and it is a great thing you are doing in New York, but it has really been the pharmacists pushing this. I get patients who come back to clinic and educate me with all that they learned from the pharmacist about the availability of naloxone. It is working together.

Peter Salgo, MD: Your analogy is apt. A few years ago, it was, “Let’s get defibrillators everywhere.” A defibrillator, I must tell you, in an unexpected location, saved the life of my best friend who went down with VFib [ventricular fibrillation]. It is so much easier to do naloxone; it is silly. To involve lawyers with a drug that has no real downside, no adverse effect, and has only an upside just seems to be saying: It is cheap, it is available, it works, and it saves lives. So what am I missing here?

Transcript Edited for Clarity

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