Wednesday, June 29, 2011

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?

9 comments:

Anonymous said...

Put a few of the "doctors" in jail FOREVER and we might see a drop in the problem. As I typed that I just realized that's not true. If these pill mills go away, where will the addicts get there fix? They'll rob us! I LOVE pharmacy!

fmaon said...

I like the card idea, but how will you be sure that the person handing you the card is actually who it's for? Perhaps have a picture as well to make this a photo ID, and have it updated every 5 years or so. Great idea.

Ryan said...

I just started reading your blog and too was distraught over the recent pharmacy murders. Thank you for writing a piece about this seemingly growing danger within our profession and practice. I think that real-time prescription data, at least for narcotics, makes perfect sense. We have MAPS here in Michigan but that is also on a delay. I look forward to reading more of your blog and hope to contribute some ideas regarding these and other pertinent issues facing our profession.

The Nail Narc said...

As far as ID for the "card" goes, why not use Biometrics? A fingerprint to access the system? Does this violate a person's personal civil rights anymore than a national database? Probably not.

Anonymous said...

With regard to legitimate prescriptions, too many CS are prescribed willy-nilly. Prescribers need to be writing for minimum quantity from ER, say one or two day's worth at the most. I had an ER doc that used to write for 4 oz of Tussionex at a time for small kids!! Another ER doc wrote for adults at least 8 oz of Codimal DH no matter what (sometimes a pint). As pharmacist, I made it my policy to fill for maximum of 2 days and leave the balance as refill. Funny how the patients NEVER showed up for the rest of the prescription.

There are too many 'extra' leftovers left around, too. There should be a place to return old prescriptions for record and disposal.

Anonymous said...

I also think that ER prescriptions for controlled drugs should have a pre-printed expiration date (time by which they must be presented for filling at the Pharmacy) on them. Perhaps 3-4 days after they were written would be reasonable.

Ryan Maag said...

I think you are all going about it the wrong way. I am amazed how oblivious you are. Let me see here. Isn't alchohol legal? Isn't it a drug? I think the problem is the DEA and the US government! I think the laws are so double stadard. People over 21 have beer at their fingertips but does everyone use it? Do you see people shooting people for it. I don't think that happens as often. I think you are all trying to go to desperate measures to control everything. Chill out a little a let people use them if they want to. Let them have some free agency. Let them ruin there lives and maybe they will hit rock bottom and see how crapy an addicts life is! I just feel like you guys are going in the complete wrong direction and you wonder why your loosing the war on drugs!

Anonymous said...

Well I can clearly see that none of you are in chronic pain and none of you have ever been turned away from a pharmacy after using the same pharmacy for your whole life 43 years with only 2 pharmacist. Today I w told that my pharmacy will no longer fill my perscriptions due to being in a different county. Yup after all those years and the same doc and pharmacist. So now I have had to go to over 28 pharmacies and 2 weeks without my medication. What should I do?! I even offered up my records so they can judge for themselves. What do I do? What about the chronic pain patients that re being turned away? What do they do? Please one of you people tell me what gives the pharmacist or the company the right to turn away legit customers due to company policy. When I then go obey the company policy and go to a WD in the same county as my doctor here is what I get. We are out. We don't have them in stock we quit dispensing when you see the person in front of you walk out with the medication. When did the pharmacies start dictating what the doctors prescribe? I thought our doctors were the ones that were well educated and take the oaths. Last time I checked it is legal to go to the doctor and have him write a Perscription and go get it filled. Am I missing something here? You guys don't have a clue. Try this. Just go to 5 pharmacies and tell them your new in town and your doc has transferred you here and you wanted to see about getting your perscriptions that you have been taking for 8 years. Wear a suit if you want. Tell me if you still think the same way. Imagine the whole time you can't walk or hardly speak due to the pain your in. Oh I forgot you to can sleep at night when you lay your head down. The people like me who have been in chronic pain for ever have to plan on how their going to go to 20 pharmacies to get there meds tomorrow. When they can't even walk. What about these people?! The database is great! Only that yes it has come about yet I am still having issues getting my Perscriptions filled. So if just one of you with all your wonderful ideas have an idea that will allow me to pick up my Perscriptions each month without all the drama please share this with me. Because I'm sure there are many chronic pain patients that would love to here your idea. Yes there are people that are abusing the drugs but what about the people that need them?! I GURANTEE if you or one of your loved ones ever have to have the pain medication on a long term basis you will change your minds very quickly! Trust me on that one. So before you start blaming everyone for the murders you should really think about what your not only saying but writing. You are grouping pain management patients with drug addicts! Thre is a difference trust me. So if any of you know where I can get my Perscription filled this month let me know. I live in Florida and have had several surgeries and have been diagnoised with cancer and I'm taking treatments. So please tell me what's fair and what's not. Due to the drug abusers you are pushing people to get there medication any way they can. That's not good. Let the people have there legal medications and if they choose to abuse then that's not your problem now is it. It just makes me sick that no one even cares about the people that need the medication. No one cares that someone that struggles to get out of bed each day has to drive 300 miles a month to get there meds filled. It is truly amazin to me that we as human beings can not get our medications filled any more without all this GD Drama! Wait my friend until you need the medication you will then see what I mean!

Anonymous said...

Well I can clearly see that none of you are in chronic pain and none of you have ever been turned away from a pharmacy after using the same pharmacy for your whole life 43 years with only 2 pharmacist. Today I w told that my pharmacy will no longer fill my perscriptions due to being in a different county. Yup after all those years and the same doc and pharmacist. So now I have had to go to over 28 pharmacies and 2 weeks without my medication. What should I do?! I even offered up my records so they can judge for themselves. What do I do? What about the chronic pain patients that re being turned away? What do they do? Please one of you people tell me what gives the pharmacist or the company the right to turn away legit customers due to company policy. When I then go obey the company policy and go to a WD in the same county as my doctor here is what I get. We are out. We don't have them in stock we quit dispensing when you see the person in front of you walk out with the medication. When did the pharmacies start dictating what the doctors prescribe? I thought our doctors were the ones that were well educated and take the oaths. Last time I checked it is legal to go to the doctor and have him write a Perscription and go get it filled. Am I missing something here? You guys don't have a clue. Try this. Just go to 5 pharmacies and tell them your new in town and your doc has transferred you here and you wanted to see about getting your perscriptions that you have been taking for 8 years. Wear a suit if you want. Tell me if you still think the same way. Imagine the whole time you can't walk or hardly speak due to the pain your in. Oh I forgot you to can sleep at night when you lay your head down. The people like me who have been in chronic pain for ever have to plan on how their going to go to 20 pharmacies to get there meds tomorrow. When they can't even walk. What about these people?! The database is great! Only that yes it has come about yet I am still having issues getting my Perscriptions filled. So if just one of you with all your wonderful ideas have an idea that will allow me to pick up my Perscriptions each month without all the drama please share this with me. Because I'm sure there are many chronic pain patients that would love to here your idea. Yes there are people that are abusing the drugs but what about the people that need them?! I GURANTEE if you or one of your loved ones ever have to have the pain medication on a long term basis you will change your minds very quickly! Trust me on that one. So before you start blaming everyone for the murders you should really think about what your not only saying but writing. You are grouping pain management patients with drug addicts! Thre is a difference trust me. So if any of you know where I can get my Perscription filled this month let me know. I live in Florida and have had several surgeries and have been diagnoised with cancer and I'm taking treatments. So please tell me what's fair and what's not. Due to the drug abusers you are pushing people to get there medication any way they can. That's not good. Let the people have there legal medications and if they choose to abuse then that's not your problem now is it. It just makes me sick that no one even cares about the people that need the medication. No one cares that someone that struggles to get out of bed each day has to drive 300 miles a month to get there meds filled. It is truly amazin to me that we as human beings can not get our medications filled any more without all this GD Drama! Wait my friend until you need the medication you will then see what I mean!