North Carolina Medicaid recipient management lock-in program: the pharmacist's perspective.

BACKGROUND: The misuse and abuse of prescription opioids have become an urgent health issue in North Carolina (NC), particularly among Medicaid patients who suffer high rates of morbidity and mortality due to abuse and overdose. The NC Division of Medical Assistance (DMA) implemented a recipient management lock-in program, which limits identified patients for a 12-month period to 1 prescriber and 1 pharmacy for benzodiazepine, opiate, and certain anxiolytic prescriptions in order to prevent misuse and reduce overutilization of Medicaid benefits.  OBJECTIVES: To (a) evaluate pharmacists' perceptions of the implementation of the NC recipient management lock-in program (MLIP) and (b) determine how the beliefs and attitudes of pharmacists could promote or inhibit its success.  METHODS: We conducted 12 structured phone interviews with NC pharmacists serving lock-in patients. Interview responses were analyzed through construct analysis, which identified themes organized into 3 domains: organization and implementation, perceived effectiveness, and acceptability.  RESULTS: Most respondents reported a positive experience with the program but expressed doubt concerning its impact on prescription drug abuse. The program successfully utilized the pharmacist role as a gatekeeper of controlled substances, and the procedures of the program required no active effort on pharmacists' part. However, respondents suggested that the DMA improve communication and outreach to address pharmacists' lack of knowledge about the program's purpose and confusion over remediating problems that arise with lock-in patients. The DMA should also address the ways in which the program can interfere with access to health care and treatment, allow patients to see multiple physicians within the same clinic, and clarify procedures for patients whose complex health issues require multiple specialists.  CONCLUSIONS: Although possible improvements were identified, the NC MLIP has strong potential for success as it utilizes pharmacists' medication gate-keeping role, while minimizing the effort required for successful implementation.

Dalfampridine: a medication to improve walking in patients with multiple sclerosis.

OBJECTIVE: To review the pharmacology, pharmacokinetics, efficacy, and safety of dalfampridine. DATA SOURCES: A search of PubMed (1966-March 2012) was conducted using the words dalfampridine and Ampyra. Bibliographies of retrieved articles were reviewed to identify additional references. STUDY SELECTION AND DATA EXTRACTION: All identified studies published in English involving the efficacy and safety of dalfampridine were reviewed. DATA SYNTHESIS: Dalfampridine (Ampyra) is a broad-spectrum potassium channel blocker that is indicated as a treatment to improve walking in patients with multiple sclerosis (MS). Dalfampridine is the only medication approved for this indication. Efficacy has been demonstrated in 2 Phase 3 trials involving patients with MS. Dalfampridine 10 mg twice daily improved walking, as shown by a higher proportion of timed walk responders in the dalfampridine-treated group (42.9% and 35%) versus the placebo-treated group (9.3% and 8%) during the 2 studies (p < 0.001). The maximum recommended dose of dalfampridine is 10 mg twice daily; higher doses are associated with an increased risk of seizures. At doses greater than 10 mg twice daily, the frequency of other adverse reactions and discontinuations was greater and showed no additional benefit. The average wholesale price of a 10-mg dalfampridine tablet is $21.12, which would make a 1-month supply of therapy cost $1267.20. CONCLUSIONS: In clinical trials, dalfampridine improved walking speed in approximately one third of patients with MS. The risk of seizures appears to be dose-related and the incidence is low at doses of 10 mg twice daily. Because of the cost, dalfampridine should be reserved for patients who meet criteria for the drug and continued only if they have an adequate response.