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Guest Editorial: The Latest Battle in Medical TreatmentCompound Medications—What Should Be Done Next?

Bruce Curnick(Bruce Curnick serves as vice president of Landmark Medical Management, a company that purchases receivables from compound-drug pharmacies. He has been involved in workers’ comp since 1982 and spent three years clerking for the Workers’ Compensation Appeals Board. For the past 10 years his focus has been on the role of pharmacy and physician practices in workers’ comp. His bachelor’s degree is from the University of California at San Diego and his juris doctorate from Western State University.)

Compounding medications is the practice of pharmacy and has its roots in the Middle Ages. It is part of the general curriculum of every pharmacy school in the United States, Canada and Europe. As our knowledge of medicines and treatment for the sick and injured improve with science, so can our physicians and pharmacists work together to take a safe, serious and beneficial approach, using combination of medicines to assist in recovery. As liability and malpractice awards continue to escalate due to overuse of prescription opioid medicines such as Oxycontin, Vicodin, Lortab and other habit-forming drugs, physician practitioners have become increasingly wary of prescribing these types of medications for pain management. In one year of a recent study, complications of oral ingestion of nonsteroidal anti-inflammatory medication such as ibuprofen caused 7,600 deaths and more than 76,000 hospitalizations. I can remember having surgery a few years back, and my anesthesiologist told me that he would use an “anesthetic cocktail” combination of medicines to administer anesthesia. Unbeknownst to me at the time, that injection into the IV location in my left arm was a “compound medication.” In fact, compounded medications are made daily in clinics and hospitals around the world. So why are insurance companies so adamant that compound medications should be eliminated? The answer is simple: their refusal to understand medical principles involved and looking merely at cost.

In workers’ comp, most injuries are orthopedic or musculoskeletal in nature. Physicians have little choice when treating for pain and inflammation when faced with an examination of a human being in acute or chronic pain. They can (1) ignore the patient’s concern (a violation of good medical practice); (2) prescribe one of many oral medications from ibuprofen to an extremely habit-forming, opioid-based oral medication and ignore the side effects; or (3) work with a pharmacist to develop a combination of medications that can provide pain management at the site of the pain without systemic side effects that oral ingestion can cause. Let’s think about it in more practical terms. You have a severe ankle sprain at work that needs treatment for inflammation and pain. You go to the doctor and he prescribes a low dose of Vicodin to deal with the pain, or perhaps a high dose of nonsteroidal anti-inflammatory medication such as Feldene or Indocin. But these medications have side effects such as gastrointestinal bleeding, liver damage and inability to safely operate machinery or drive an automobile. Certainly, with opiods such as Vicodin, the patient cannot simply function in a working capacity at all and is constantly getting “high” from the medication. These conditions happen in all of us. We know how the patient will react to these commonly prescribed pain relievers. So what happens to your sprained ankle?  A transdermal-applied compound medication is what many doctors now prefer. In this case, the physician would write a prescription and/or consult with a compounding pharmacist to make a medicine that can simply come in a cream or gel form and be applied directly to the ankle. Medicines such as Ketoprofen, Flurbiprofen and Diclofenac are all FDA-approved anti-inflammatories proven to work well when applied in this way. They can be dispensed only with a prescription. The pharmacist simply prepares this medication at the direction of the physician for administration to the patient. The result: minimal or no systemic side effects, non-habit-forming medication and effective pain management. In many circumstances, the patient can return to work and apply the medication at work for effective and safe relief.

As the dangers of many potent medicines become better known, we should congratulate our medical profession on taking the time to place patient care first and become innovative in the practice of medicine. Some legitimate cost controls need to be implemented to prevent opportunists from trying to capture excess profits from this practice. Physicians and pharmacists want to work with payors to establish cost containment with reasonable controls. Now is the time for all sides to come to the table because compound medications are here to stay.



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