The Pharmacy Chick

Flying the coup in retail

Misuse and Abuse. A growing issue

Filed under: Uncategorized — pharmacychick at 5:29 pm on Tuesday, February 16, 2016

Misuse and Abuse..Dur (drug utilization reviews for the TLA deficient), CMR, Fraud Waste and abuse..All of these are hot terms in pharmacy right now.  Between Boards of Pharmacy, CMS and PBM’s we are attacked on all sides by agencies trying to monitor what we dispense, who we dispense to, how much we dispense and how often we dispense it. More often than not it focuses on controlled substances and expensive drugs…they can levy hefty fines and chargebacks on these.

What that means is that pharmacists now get to don the hat of compliance officer and policeman. It used to be that Overuse was the only thing that we would get harassed about by agencies, but any type of misuse or abuse is monitored  by our overlords.

Misuse is not only over use of a medication. Its any deviation from the directions provided by the prescriber.  This also includes under utilization, or use for any condition for which it wasn’t prescribed.( off label use)

Everyone has misused a drug at some time or another.  I had a bad cough 2 months ago and my doc was being a real pill and wanted an appointment to be seen and it was nearly a week away… IN the mean time Im hacking my guts out.  I had some old vicodin from a shoulder injury so I used it for my cough.  Technically misuse but it worked like a charm.  I occasionally forget to take my cholesterol med, thats technically misuse also.

Recently we received notification that all controlled substances WILL ( not should) but WILL be monitored for misuse and abuse. Days supply will be checked and monitored and days between refills will be reviewed and monitored for accuracy.  What this means is that someone is watching our dispensing of controlled substances.  Opiate abuse is rampant in the United states and the pharmacist is the infantryman trying to do battle from both sides. Customers who need ( or want) their pain meds for genuine need or abuse..and doctors who feel compelled to keep writing scripts despite admonitions from agencies  who ask them to refrain or reduce prescriptions.

Personally, the only reason I care about this subject is a piece of paper on the wall called my license.  I value that license because it pays my bills each and every month.  without it, I cannot come into the pharmacy and make a living.  If I dispense narcotics or any controlled substances  outside proper procedures I can lose that license.   I wrote a piece a long time ago called” Cash is not Carte Blanche” and to this very day I get people ripping me a new a$$hole because they think I am a judgmental whore for not giving narcotics to everyone who claims to need them.   Read the entire post and substitute Zestril for Norco in it and see if you have the same reaction.  All early refills need justification and just because he wanted to pay cash doesn’t mean he gets the refill….and it doesn’t matter the drug except for the fact the 1 is controlled and the other is not. Nevertheless, the actual content of the post got completely lost by commenters getting pissed, all of whom I am guessing take opiates. Why else would you if you didn’t?

let me share some some factoids: cut and pasted from the American Society of Addiction Medicine Opiate addiction 2016 facts and figures


Opioid Addiction

  •   Opioids are a class of drugs that include the illicit drug heroin as well as the licit prescription pain relievers oxycodone, hydrocodone, codeine, morphine, fentanyl and others.
  •   Opioids are chemically related and interact with opioid receptors on nerve cells in the brain and nervous system to produce pleasurable effects and relieve pain.
  •   Addiction is a primary, chronic and relapsing brain disease characterized by an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
  •   Of the 21.5 million Americans 12 or older that had a substance use disorder in 2014, 1.9 million had a substance use disorder involving prescription pain relievers and 586,000 had a substance use disorder involving heroin.
  •   It is estimated that 23% of individuals who use heroin develop opioid addictio.4 National Opioid Overdose Epidemic
  •   Drug overdose is the leading cause of accidental death in the US, with 47,055 lethal drug overdoses in 2014. Opioid addiction is driving this epidemic, with 18,893 overdose deaths related to prescription pain relievers, and 10,574 overdose deaths related to heroin in 2014
  •   From 1999 to 2008, overdose death rates, sales and substance use disorder treatment admissions related to prescription pain relievers increased in parallel. The overdose death rate in 2008 was nearly four times the 1999 rate.  In 2012, 259 million prescriptions were written for opioids, which is more than enough to give every American adult their own bottle of pills.  Four in five new heroin users started out misusing prescription painkillers. As a consequence,the rate of heroin overdose deaths nearly quadrupled from 2000 to 2013. During this 14-year period, the rate of heroin overdose showed an average increase of 6% per year from 2000 to 2010, followed by a larger average increase of 37% per year from 2010 to 2013.
    •   94% of respondents in a 2014 survey of people in treatment for opioid addiction said they chose to use heroin because prescription opioids were “far more expensive and harder to obtain.”Impact on Special PopulationsAdolescents (12 to 17 years old)
      •   In 2014, 467,000 adolescents were current nonmedical users of pain reliever, with 168,000 having an addiction to prescription pain relievers.
      •   In 2014, an estimated 28,000 adolescents had used heroin in the past year, and an estimated 16,000 were current heroin users. Additionally, an estimated 18,000 adolescents had heroin a heroin use disorder in 2014.
      •   People often share their unused pain relievers, unaware of the dangers of nonmedical opioid use. Most adolescents who misuse prescription pain relievers are given them for free by a friend or relative.
      •   The prescribing rates for prescription opioids among adolescents and young adults nearly doubled from 1994 to 2007

     Women are more likely to have chronic pain, be prescribed prescription pain relievers, be given higher doses, and use them for longer time periods than men. Women may become dependent on prescription pain relievers more quickly than men.


    Ive come to the realization that most of the people who get hot and bothered over this subject come across as narcissistic  soap boxers who might just as well wear a shirt that says ” narcotic takers lives matter”..since they seem to get all puffed up anytime this subject is broached. They seem to believe that 1) we are the judge and jury in the pharmacy  and 2) we look all day for opportunities to deny people their meds. Of course if the said person were to OD and die as 18893 people did in 2014, I am sure I would be first to be sued by some family  member wanting blood for the death of their “loved” one because I filled their med early/too often/inappropriately.

Lets look at those two assumptions:  Judge and Jury:  In my pharmacy I have 2 rather large documents: the first is the policy and procedure manual of my business…a rotund tome of over 300 pages.  I also have the Federal and State laws governing pharmacy printed in a enormous binder.  It looks somewhat like a printed version of the US TAX CODE in its size and complexity.  THESE two documents are my judge and jury.   They detail what I do, how I do it and the penalties for doing what I am not supposed to do and NOT doing what I am supposed to do.    And tho I do not have physical copies of these in my pharmacy I am also subject to rules of CMS ( center for Medicare/Medicaid Services)  and nearly every insurance company that we do business with.   Deciding ON my own when to refill a prescription is pretty low on this list.   Using ” good judgement” is pretty much pre-decided often by a governing agency, the insurer or the prescriber him/herself.

Assumption 2: we look all day for opportunities to deny meds:  HAHAHAHAHA.  As if I don’t have enough on my plate.  The goal for every rx I have is simple.  Fill it to completion without a hassle and get YOU out of my pharmacy ASAP with all the necessary tools and information required by law.  Discovering a rx is too early is one of those hassles I didn’t need and didn’t ask for.  No pharmacist goes home at night revelling in the joy of rx’s turned away.  We also don’t spend much time mourning over the plight of all our patients any more than YOU as a patient are concerned about the working conditions/mood/heath/life of the pharmacist you handed your rx to. Its a JOB….a Vocation we have to make money and supply a life for our family.  Its not our passion or obsession …at least not for any pharmacist I have met who have practiced for a few years. To think that we have some kind of vested interest or enjoyment in keeping meds OUT of the hands of the people who should have them is another narcissistic tendency.

For anyone who has bothered to read this far I applaud you.  type ” I read it all” in the comments line to prove it LOL

In summary, its rather are the rules of engagement for  Opiates/benzodiazepines and any other controlled substance we dispense to keep us all on the right size of compliance officers and the law:

  1. WE, the courts and the govt use the hard copy directions as a legal document and we are all are bound to that document. If 90 tabs are given to a patient as a 30 days supply then its  to last 30 days . If a patient comes in 8 days early for a refill or ask for a new rx from the doc then he/she best be able to produce 8 days worth of meds to show the doc if he were to ask or have new directions to support that change.  Ive got several docs in my area now who will refuse to even  issue the next rx till 30 days have passed. Most will put a fill date on these rx’s. They aren’t all idiots just because some behave that way
  2. regulatory agencies are narrowing in on overprescribing and inappropriate prescribing of all controlled drugs.  We have to watch our backs, and if that means telling a patient that we aren’t going to fill a controlled substance early then so be it.
  3. As a patient, do not engage in behavior that would lead your physician /pharmacist/nurse/insurer to assume that you are abusing or misusing a drug.  This includes but not exclusive to: a) taking more medication that is currently prescribed on the label you have on the bottle  b) finding creative ways to get more ” oh I fell last night”  ” I turned my ankle” ” I slipped on the wet floor” excuses have a way of adding up. c) losing meds more than once ” they were stolen on the bus” ” they dropped down the sink” .  Treat your meds like cash.  Would you be careful if you had a handful of 20 dollar bills? and d) going to multiple places and urgent care looking for pain treatments.
  4. if your health deteriorates where you feel you need to increase your doses, you must do it with the permission and cooperation of your prescriber.  You are not autonomous in deciding what is right for your body when it comes to pain management.  Its a team effort and adding more medication may not be the right solution.
  5. Don’t use verbal threats or become argumentative with any of your health care professionals. Thats pretty  much a guarantee that you aren’t going to get any cooperation from any of us.  There are certain red flag behaviors we have been taught to look for and defensive and argumentative behavior is one of those items.
  6. Physicians: use your states Prescription Drug monitoring program if you have one. Any patient presenting “pain” that isn’t obviously quantified with a trauma should be looked up and examined for controlled substances. Any patient who receives regular opiates should also use other modalities to treat and monitor pain. “Just take one more” is not an appropriate modality. Don’t overprescribe opiates.  For instance. Mr Chick received 90 oxycodone for his back surgery and 30 percocet for his appendix removal. Both physicians said ” you shouldnt have too much pain, but here is a prescription.  REALLY was that necessary?  He took 8 oxycodone over first 3 days and that was all he needed.
  7. Pharmacists, its simple math, not an ethics dilemma.  If the patient is supposed to have meds to last 30 days and they are coming in any more than 1-2 days early, then its reasonable to assume that they should have at least 1-2 days left. IF they ask for an  early fill, its more than acceptable to ask the doctor for permission or a reason to document for legal. Leave emotion out of it.  If the patient claims they are out then its really not your problem. Again, its simple math. Now it becomes an issue for the dr and the patient to work out as to why what was given to the patient “ran out”.  90 tabs  at 1 tab 3 times daily will never be anything but 30 days.  its just math. Thats the great thing about math, its not subjective….
  8. lastly, understand that it IS ALL health care professionals “business” to know why patients take their medication.  I get really tired of being insulted by patients and some clinics when I am forced to question a prescription and be told ” This is between me an the patient” or ” Its none of your business”.  Well yes it is…its is very  much my business. And if you question that statement, let me have the DEA , the Board of Pharmacy, your insurer  or the families of the 18,893 people who died of opiate overdose in 2014 explain it to you.