Pharmacists feel the pressure in fight against opioids

Kim Robbins didn’t usually get asked for the same drug twice by a single customer. But one day in 2005, she finished a shift at the Happy Harry’s pharmacy in Harrington and then drove up to Dover to cover a shift for a friend. When a familiar face came in asking to fill a prescription of painkillers, she knew something was wrong.

“The first prescription I filled was for someone who had already filled 180 Vicodin with me in Harrington earlier that day,” she said.

Robbins later made some calls to other pharmacies and discovered that the man had been filling prescriptions all over the area, racking up thousands of painkillers in a single week.

“The only reason we caught this guy is because I covered for that girlfriend,” she said.

That was more than a decade ago — before opioid abuse became a political talking point and overdose deaths a weekly headline. The abuse of drugs such as Vicodin and OxyContin has since become a national epidemic. Between 1999 and 2015, fatal overdoses from prescription drugs quadrupled. In 2015, the number of deaths reached 15,000 people nationally, according to the Centers for Disease Control.

In Delaware, the number of overdose deaths jumped from 228 in 2015 to 308 in 2016. Much of the increase was due to an uptick in the use of powerful strains of heroin, a trend many attribute to prescription drug users moving on to illegal street drugs. Prescription opioids still account for nearly 40 percent of those deaths.

State regulators, meanwhile, have rolled out a series of new rules to combat the problem. The Department of State proposed a set of laws, which took effect April 1, targeting over-prescription of opioids. The rules include an initial seven-day limit on prescriptions and a requirement that doctors look into their patients’ narcotics history. These rules track with other reforms from around the country that limit how many narcotics patients can get from a single prescription.

In March, Attorney General Matt Denn brought a series of bills to the legislature that would, among other things, improve access to treatment for addicts and use data to identify abuses.

Where do local pharmacists fit into these efforts? Many already feel significant pressure to stop drugs from getting into the wrong hands. But when it comes to the opioid epidemic, which has touched doctors, regulators, pharmaceutical companies and countless communities, some feel the buck shouldn’t stop with them.

“I’m tired of being a drug cop,” said Robbins, who now works at Atlantic Apothecary in Middletown and is a member of the Delaware Board of Pharmacy, which helps regulate the industry. “We need to spend more time helping people and less working as an arm of law enforcement.”

Robbins said she must now evaluate every patient seeking a controlled substance or narcotic. That means reading a patient’s behavior for signs of addiction while also digging into their prescription history and finding patterns that may suggest abuse.

“It’s basically making sure the checks and balances have been completed,” said Jeffrey Smith, owner of Manor Pharmacy in New Castle. “And what I mean by that is making sure the patients aren’t abusing the system.”

Keeping up this level of vigilance can be draining, however, and some local pharmacies have begun to turn away new patients to avoid the trouble.

“We keep a tight watch on the customers that come here, and when it comes to the narcotics we have just the regular people,” said Johnnymae N’dione, pharmacist and owner of Living Well Pharmacy in Middletown. “We try not acquire too many more because we don’t want to deal with the headache.”

If something seems wrong with a customer, the prescriber or doctor may also be missing the signs. This puts pharmacists in a difficult position between patients and their caretakers.

“You kind of feel like you’re policing it, but you don’t really have any power or authority to police it,” said Erik Mabus, owner of Bayard Pharmacy in Dover. “You’re just kind of using your best judgment, and sometimes that means you may turn away someone in legitimate need of pain medication because you didn’t have a good feeling about the doctor.”

One policy that pharmacists widely embrace is the state’s Prescription Monitoring Program (PMP), which created a database tracking all narcotic prescriptions. Launched four years ago, the system draws over 40,000 inquiries per month by 5,700 health professionals across the state, according to the Department of State.

“That data is critical to prescribers and other pharmacists who can use it to promote safe prescribing and to detect possible illegal use of opioids,” said Secretary of State Jeff Bullock, who has made the opioid epidemic a priority.

Pharmacies are required to submit information on narcotics at the end of each day, but they are not required to check the system before serving a customer. Many still do as a way to ensure against abuses. “To be honest, it helps on those times that we already had an instinct or a feeling,” Mabus said. “It’s very rare that I go in there that I’m completely surprised.”

Then there’s the problem of state lines. All it takes is a trip across the Pennsylvania state line or the Delaware Memorial Bridge for someone to access a whole new set of pharmacies without their background information.

“Even with the PMP, some patients go out of state for stuff,” Mabus said. “They’re all good tools and they help,
but nothing is 100 percent.”

That hasn’t stopped regulators from cracking down on pharmacists.

“It’s being put on the pharmacies’ plate that if you don’t follow the rules exactly you’re under the hangman’s noose,” said Smith, who declined to specify where exactly the regulatory pressure was coming from. “In essence, your license could come off the wall.”

Hooshang Shanehsaz, vice president of the Board of Pharmacy and director of pharmacy at Cardinal Health, who spoke from his personal experience, said the pressure comes from a mix of factors. He pointed to a lack of coordination between doctors and pharmacists, a lack of clear rules for narcotics, and the push by policymakers to address the problem.

As for consequences, he explained, pharmacists can be brought before the Board of Pharmacy following a complaint and eventually be fined, suspended, or even have their license taken away.

“If the attorney general’s office feels that there was something that was done that was not correct, they very well could be held responsible — not even just the store but the pharmacists themselves,” Shanehsaz said.

Regulators, for their part, have stressed collaboration over punishment.

“We’ve viewed it as a collaborative effort more than a strict regulatory one,” said Doug Denison, spokesman for the Department of State’s Division of Professional Labor.

The new regulations from the Department of State, which took effect April 1, take aim at doctors, forcing them to adopt the PMP along the same lines that pharmacies have.

“Pharmacies have historically been the ones to actually recognize and report the problems most often,” Shanehsaz said. “That’s why the new regulations that have passed did not really affect the pharmacies, but did affect the prescribers.”

He chalks up the relative embrace of the PMP on professional culture, rather than regulatory pressure. But whatever the source, violations are few and far between. A review of 2016 state enforcement actions found only two violations related to opioids. He adds that a sense of urgency created by the epidemic has also encouraged pharmacists to grit their teeth and learn how to navigate new policies.

“We’ve recognized that there is a problem out there, and pharmacies truly do see themselves as part of the solution,” Shanehsaz said.

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