Clearly our laws and health insurances as designed contribute to the misuse of opioid medications.
The route to addiction often begins with an opioid prescription for managing pain; there are more than 257 million opioid prescriptions written each year. Not all of these prescriptions are necessary, and more importantly, many are not managed in a way that provides the needed pain relief but avoids unintentional abuse or addiction. Without proper management of these medications, it’s easy to become dependent.
The federal Drug Enforcement Agency (DEA) establishes the rules that control the manufacturing, distribution, prescribing and dispensing of controlled substances. Created by an executive order in 1973 by President Richard M. Nixon, its charge was, and is, “an all-out global war on the drug menace.” The DEA performs a valuable policing function for controlled substances, but it acts as an enforcer, not a health-care mandate.
The DEA has strict requirements for both prescribing and dispensing controlled substances. Two common opioids, OxyContin and Vicodin, are classified as “Schedule II” products. To prescribe or dispense these products requires a special provider registration with the DEA. A pharmacist can’t refill a “Schedule II” prescription, and if patients wish to receive only a portion of the original order, the balance of the prescription is canceled.
Allow management of prescription quantities
The DEA should review its rules on the handling of “Schedule II” prescriptions to allow pharmacists to manage prescription quantities. Pharmacists could help patients achieve the desired pain relief from these medicines, reduce misuse and there would be fewer unused medications in the medicine cabinet.
Health-insurance programs also contribute to the problem by encouraging the ordering and dispensing of large quantities of medications – typically 90-day supplies for one copayment. Patients want to save as much money as possible so many people request the larger quantity prescription that is a better deal. This results in excess medication and cost when the larger quantity is not used.
Some patients have never taken an opioid medication and don’t know how long it will be needed, how they will respond to the medication or if the medication will be needed at all; ibuprofen or acetaminophen might work just as well as an opioid. A rule change that would allow a patient to get a portion of the amount prescribed at the initial prescription fill and the remainder when, or if, needed within a specified period of time would improve the management of these medications.
Revise the design of insurance benefits
Insurance benefit designs should be revised to allow the patient to receive a “starter package” for any new prescription to try the medication. If the medication works well, the patient would get the remainder without having to pay additional copayments. The pharmacist who dispenses these prescriptions is an important asset in assisting patients in the appropriate use of these products as well as reducing costs.
We need to rethink how we prescribe and manage all medications, including opioids. We need to recognize that our state and federal drug regulations, as well as insurance drug-benefit policies enable an addiction problem that is fueled by over-prescribing and inadequate patient management.
Let’s look for ways to remove the mandated enablers. We can start by updating the 43 year-old “all-out global war on the drug menace” executive order so it also considers general health.
Lowell J. Anderson practiced pharmacy in St. Paul before joining the faculty at the University of Minnesota College of Pharmacy. He has served as president of the Minnesota Pharmacists Association, Minnesota Board of Pharmacy and American Pharmacists Association; and vice-chairman of Physicians Health Plan.
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