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 drove up to Dover to cover for a friend. When a familiar face came in asking to fill a prescription of painkillers, she knew something was off.

“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 same 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 friend,” 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 like Vicodin and OxyContin has since become a national epidemic. Between 1999 and 2015, fatal overdoses from prescription drugs quadrupled. In Delaware, the number of overdose deaths jumped from 228 in 2015 to 308 in 2016.

State regulators have rolled out a series of new rules to combat the problem. The Department of State proposed a set of new regulations, which took effect April 1, targeting over-prescription. The rules include an initial seven-day limit on prescriptions and a requirement that doctors look into their patients’ narcotics history. The state-led reforms track with other efforts from around the country that limit or qualify access to opioid-based drugs.

Where do local pharmacists fit into these efforts? Stopping drugs from getting into the wrong hands is part of the job. 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, 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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  1. Pharmacists can be punished for getting opiates in the “wrong hands” but there is no punishment for failing to get opiates in the “right hands”… a pt that has a valid medical necessity for the opiate.
    Should inappropriate denial of care be considered unprofessional conduct, pt abuse.. because throwing a opiate dependent patient into cold turkey withdrawal can be FATAL.
    The bureaucrats have set up the system that it is easier for Pharmacists to “just say no”. According to our Surgeon General addictions are a ‘mental health disease” not a moral failing and yet our system continues to treat addiction as a crime.. except for the 45 million alcoholics and 35 Nicotine addicts. Those two drugs kill 550,000 people annually.

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  2. Delaware has done a great job improving the security chain of custody between the prescriber and the dispenser by mandating the use of only preprinted Tamper-Resistant prescription forms. This simple requirement means that somehow a prescription forger must acquire this print media. However and this is very important for all Delaware health care providers to be aware of. If you are using a key lock to prevent opening of the laser printers paper tray that contains this valuable media – you are vulnerable to theft. There are more than two dozen different ways that this media can be removed from a locked laser printer without detection in less than 45 seconds. Intelligent laser printer paper tray locks that prevent the unauthorized removal of the print media are now available. Compromise should never occur when it comes to security.

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  3. I am one of many Delaware law abiding citizens that have been harmed by stricter guidelines on refills for chronic pain sufferers this month. I have a number of health conditions including klippel feil syndrome, and the resulting rapid spinal degeneration that causes constant agonizing pain. Last week I called in my refill request to the doctor who has treated me for 8 years. The next day I had painful invasive diagnostic tests. I saw my doctor in April and my next appointment was scheduled for June 15th to review mri results. I was denied a refill unless i see the doctor each time. I have gone a week with no pain meds. Fortunately I have not gone through withdrawal but I have been praying for those who did. I have already had one failed back surgery and recent emg results show worsening nervedamage. I have 16 more days before i can see the doctor. In the meantime I am nearly screaming with pain while I care for a husband confined to a wheelchair. My blood pressure spikes when my pain is not controlled and tonight it’s 195/118. Not good. This law is punishment for those with valid need for opiates. It will do nothing to change the behavior of HEROIN LACED WITH FENTANYL using addicts. It does cause a 200% increase in copay costs and the same decrease in the face time with my doctor. There is no way for a patient to find out what is entered into the database and correct errors. If you want to curb criminal behavior start by making addicts face punishment for illegal activities. Don’t take the dignity and lives of the truly disabled people who are following the rules.

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  4. This article revolves around the struggle done by the pharmacist against opioids, as they pressurized by some of the drug addicts. Its really a very hard task to tackle those peoples as they prescribe those opioids by themselves and not get traced by anybody easily. Very good and informative article regarding this matter.

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