Curbing the narcotic problem

By now you have probably heard about the Father's Day incident on Long Island that left two pharmacy employees and two customers dead, victims of an armed robbery. Apparently the gunman was trying to obtain controlled substances for his wife.

If you run over to Google and search for "pharmacy" in the news, you'll get a steady stream of stories about robberies and thefts at the pharmacy. A few weeks ago, up until the Long Island incident, the pharmacy stories revolved around the murder conviction of an Oklahoma pharmacist who emptied his gun into a man who had attempted to rob his pharmacy.

Around the same time there were stories floating around about a Michigan pharmacist who fought back against some robbers, unloading his weapon during a middle-of-the-night robbery. He was subsequently terminated for his actions.

These aren't the headlines we want to see for the profession of pharmacy. But the reality that we face today is that there are many addicts in this county, and they are becoming bolder in their attempts to obtain controlled substances. Pharmacies are the places who the controlled substances are, therefore pharmacies are the targets.

What are the reactions to these events? New York Senator Chuck Schumer has come out with a plan to require prescribers to undergo additional training before being able to prescribe narcotics like Vicodin and Percocet. His plan also calls for increased penalties for people who rob pharmacies.

Prior to the Long Island incident, the APhA (in Pharmacy Today) was reporting on the White House's plan to curb prescription drug abuse. For the last several months we've heard about the opioid REMS (Risk Evaluation and Mitigation Strategies) requirements that have been in the works.

The opioid REMS program calls for voluntary physician training when it comes to prescribing opiates (although there is talk of linking training to DEA registration). It also calls for pharmacists to distribute a MedGuide along with each prescription for the affected products.

Other projects/programs that are being used to help curb the abuse of narcotics include prescription drug monitoring programs (the one in my state is not real-time, it has a two-week lag), prescription drug take-back days, and Cephalon's when good medicines become bad drugs program.

As a practicing pharmacist, these programs do absolutely nothing to stop the abuse of narcotics. Anybody who works in community pharmacy knows how people will do or say anything to get their drugs. I honestly don't think handing a patient an extra sheet of paper telling them how the opiates might be bad for them will really affect their efforts to obtain morphine. A coloring book for kids isn't going to keep an addicted mom from deceiving a clinic physician in an attempt to score some hydrocodone. These programs may make non-practicing pharmacists feel good about doing something to curb the narcotic problem, but do they really do anything? In my opinion, the answer is no.

So what is the solution?

There isn't one. But that doesn't mean that steps can't be taken to attempt to slow things down. The solution isn't one that falls strictly to the medical and pharmacy professions. It includes law-enforcement and the federal government. I won't go into the details of what the cops and feds should do, let's just say that they needs to be involved even more than they are.

For those of us in the medical professions, we need to have real-time information provided to us, as well as having security measures in place for the protection of the employees at the pharmacy.

When a patient visits a prescriber, there needs to be a means to relay to the pharmacy what was actually prescribed. We've all had somebody present a prescription for Percocet or Vicodin from the ER late on a Saturday. In your gut you know that there was a second prescription issued, but somehow it was lost between the ER and the pharmacy counter.

As much as I hate the thought of a centralized database, I propose a centralized database that records everything that has been prescribed as well as what has actually been filled for a patient. The process is simple... any time that you visit a prescriber you must present your identification card. The prescriber swipes the card thru a reader and is able to see what meds you have been prescribed, who prescribed them, what you actually had filled, and where you had it filled.

Before releasing you with your prescription, the prescriber would record what medications they were prescribing and upload it to the database. When the patient visits the pharmacy, they would hand over both their prescriptions and the identification card. The pharmacist would be able to see what the patient should be having filled and compare it to what is actually being filled. If you don't present all of the scripts or only request the narcotics, the pharmacist records it in the database. That way future prescribers and pharmacists have a better picture of the behaviors that a particular patient has used. Ideally diagnosis codes would be included as well, so all of the health care system would know what the patient's chief complaints have been.

I would like to see the diagnosis code be a required part of the prescription, similar to Medicare B testing supplies. When a prescription is filled, the DEA number, NDC number, quantity, and diagnosis code would be transmitted to the DEA. That way the DEA could track (in real time) which prescribers are ordering which medications for particular diagnoses. A family practice physician who suddenly starts prescribing 720 oxycodone 15s, 120 Percocets, and 60 Oxycontin 80s to every third patient for chronic lower back pain could be stopped before they draw every addict in a fifty mile radius to their practice.

Those steps may help to lessen the chances of creating addicts, but the pharmacies need to be protected from the current addicts. This is where it gets a bit dicey. Pharmacists wear it as a badge of honor that we are the most accessible health care provider. But I don't think any of us want to see our accessibility lead to the death or injury of another pharmacy worker.

I have absolutely no problem with the thought of working behind bulletproof glass. Heck, I'd work out of a bank vault with drawer (similar to a drive-thru set-up) if it means keeping my staff safe. Time-delay safes for narcotics...absolutely. No narcs after 6 PM...sounds good. I've had armed guards escort me from the pharmacy lab to the front door before, then watch me from the door as I've crossed the parking lot to get to my car. If it keeps me safe, I'm for it.

Anyhow, it's getting late for me. I thought I'd share some of my thoughts on the narcotic problem that is affecting our profession as well as offer up some solutions. What are your thoughts?