To prevent and limit dependence on opioid analgesics, which frequently leads to a risk of withdrawal symptoms in the event of sudden or too rapid cessation of intake, health insurance and pharmacists’ unions have agreed to include patient support. under level II analgesic treatment in amendment No. 1 to the pharmaceutical convention, finally signed on June 10 by the Federation of Pharmaceutical Unions of France (FSPF) alone. This new mission can be offered in all pharmacies since January 8.
The support comes in the form of a short interview (5 minutes) carried out during the first renewal of tramadol, opium powder, codeine or dihydrocodeine. Nalbuphine is also mentioned.
Why at the first renewal? “The objective being to measure the patient’s degree of dependence, it is then necessary that this interview is not carried out during the first delivery but from the second delivery”, justifies health insurance. Patients on stage II analgesic opioids over the age of 18 who have received the first delivery in the previous twelve months are eligible. According to health authorities, 5% of 5.8 million patients are affected.
The POMI questionnaire at the center of the interview
The interview is conducted by a pharmacist who, according to the conventional amendment, must have a confidential space. But for the Federation of Pharmaceutical Unions of France (FSPF) and the Union of Community Pharmacists Unions (USPO), the interview is not necessarily carried out in this space. “For me, the interview can be done at the counter. It is a short interview, like the interview for pregnant women. But in certain cases, it will undoubtedly be preferable to conduct it in the confidentiality space. estimates Pierre-Olivier Variot, president of the USPO. No specific training requirement either. “The pharmacist must ensure that his knowledge on this subject is up to date in order to best meet the needs of these patients,” only requires the conventional amendment.
In practice, during the interview, it is appropriate to:
– Remind the risks associated with opioid medications, particularly in the event of prolonged use: misuse and/or risk of addiction with the impossibility of stopping consumption, accompanied by a compelling need to consume the substance. Furthermore, opioids are the cause of other undesirable effects: digestive disorders (constipation alleviated by healthy-dietary measures associated with laxative treatment often necessary in the event of chronic treatment; nausea, particularly at the start of treatment, limited by a antiemetic), urinary retention, pruritus, tremors, clonia, confusion, impaired alertness (attention when driving), dyspeptic disorders, risk of convulsions and respiratory depression which may jeopardize the prognosis vital ;
– Remind the rules of good use: respect the prescription (doses, spacing between doses, route of administration, duration of treatment) and take the minimum effective dose; do not store in your medicine cabinet and return unused doses to the pharmacy; not recommending treatment to another person, etc. ;
– Warn about certain drug combinations: tramadol and triptans or antidepressants such as SSRIs and SNRIs (increased serotonergic effect); opioids and alcohol (increases the risk of coma and respiratory depression); additional paracetamol intake with opioid/paracetamol combinations which may lead to liver toxicity; in a context of codeine dependence, the codeine/ibuprofen combination can cause serious renal, gastrointestinal and metabolic damage, sometimes fatal, etc.
The main objective of the interview is to complete the POMI questionnaire (Prescription opioid misuse index, see box) aimed at assessing the risk of dependence. A positive answer to at least two questions suggests a current risk of misuse. To conduct the interview, the pharmacist must use the materials developed by health insurance: an interview sheet, to be completed, and a memo sheet are made available on ameli.fr.
Traceability and actions
The interview form completed by the pharmacist must be archived in the patient’s shared medical record (DMP) and sent to the attending physician by secure health messaging (MSS). “I strongly advise pharmacists to set up the validation procedure with the CPS card to query amelipro because, when you connect securely, you have access to the name of the attending physician,” suggests Philippe Besset, president of the FSPF. The pharmacist keeps a copy of the interview sheet in electronic format which he makes available to the health insurance medical control department. What happens next depends on the result of the POMI questionnaire.
If the pharmacist suspects an overdose (POMI questionnaire ≥ 2), he alerts the prescriber and the attending physician via MSS, unless the patient objects. “Particular attention will be paid if the patient has several different prescribers for these analgesic treatments,” adds the conventional amendment. “If the treatment is continued for several months, the pharmacist must be extra vigilant during subsequent deliveries, particularly depending on his conclusions at the end of the interview,” also explains health insurance. “The transition to dependence happens very quickly. Overall, it is in the first month that everything is decided. But for chronic treatments, if it is not necessarily necessary to carry out maintenance at each renewal, the patient will have to be reminded of the dangers of dependence.explains Pierre-Olivier Variot.
An “EPA” act code for 5 euros
For all this work the pharmacist invoices during the first renewal of treatment, the act code “EPA” at the rate of 5 euros including tax, increased by a coefficient of 1.05 in the overseas departments and communities. On the invoice, the pharmacist enters his identification number in the prescriber zone and in the performing zone, as well as the date the interview was carried out as the execution date. The maintenance is covered 70% by health insurance, or even 100% depending on the patient’s situation. Please note, the act code must be invoiced alone, “that is to say independently of any other billing (medications, LPP, etc.)”insists health insurance. Only one interview is carried out per patient over a period of 12 months.
However, the fight against opioid addiction does not stop there. In addition to these specific interviews and the obligation of a secure prescription for tramadol and codeine from March 1, the National Agency for the Safety of Medicines and Health Products (ANSM) is currently working to implement place of pictograms and/or special information to be placed on boxes of opioid medications.
The POMI questionnaire
Adapted to France, the POMI scale (Prescription opioid misuse index) is a simple tool for detecting an opioid use disorder, validated by the High Authority for Health (HAS). It includes 5 questions to which the patient answers yes or no:
– Have you ever taken this/these pain medication(s) in a larger quantity, that is to say a higher quantity than that which was prescribed to you?
– Have you ever taken this/these pain medication(s) more often than prescribed on your prescription, i.e. to reduce the time between two doses?
– Have you ever needed to refill your prescription for this/these pain medication(s) earlier than expected?
– Has a doctor ever told you that you are taking too much of this pain medication(s)?
– Have you ever felt high or had a stimulating effect after taking this/these pain medication(s)?
Two or more positive responses suggest a current risk of misuse. The attending physician and prescriber must be alerted.
Opioid overdose and the benefit of naloxone
Patients treated with opioid analgesics are at risk of overdose, particularly during initiation, or in the event of misuse of the treatment or dependence.
Signs of opioid overdose are a combination of symptoms with miosis, unconsciousness and respiratory depression which can lead to respiratory arrest and death.
The first thing to do is to quickly call the SAMU via on the 15th after protecting the person. To avoid death while waiting for the arrival of emergency services, a first dose of naloxone, an opioid antidote, must be administered. A ready-to-use kit (Prenoxad, Nyxoid) is available in pharmacies. A second dose of naloxone should be administered 2 to 3 minutes later if there is no improvement, or to prolong the antidote effect of naloxone if help has not arrived.
