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From a pharmacist: How our policies enable the opioid addiction epidemic

Clearly our laws and health insurances as designed contribute to the misuse of opioid medications.

Lowell J. Anderson

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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Comments (6)

  1. Submitted by Pat Terry on 05/04/2016 - 08:17 am.

    Marijuana

    No discussion about opioid abuse is complete without discussing marijuana. Extremely effective for at least some types of pain. Impossible to overdose.

  2. Submitted by Jim Million on 05/04/2016 - 09:29 am.

    Simply Sane and Straight Talk by Author

    Thanks for voicing these simple points of supervision. Most MDs are judicious in prescribing opioids here in Minnesota; however, even prescription review by Primaries can be tepid with respect to items written by others, particularly specialists directing chronic conditions treatment. Everyone is extremely busy these days–and, Primaries may not wish to step on toes. I have noticed a much more acute monitoring of opioids in the last few years. My GI specialist simply will not write them, clearly an exception to the apparent rule.

    The concept of starter doses is fundamentally principled here, given the rapid evolution in the pharma market, especially the FDA fast track program to get important drugs to market sooner now, with ongoing aftermarket scrutiny. Given what I long ago labelled the “co-pay/no pay” prescription pricing of most plans, patient accountability has been reduced to the extent of pocketbook feedback. Pharmacies in national chain stores have become somewhat like fast food vendors, serving repeat customers for many popular offerings at modest price.

    Starter doses would prove quite helpful here, it seems, especially if a strong feedback link is established. Physicians once provided this service via “samples” distributed to them by drug company detailers and given as trial doses to patients. That’s no longer a direct feedback mechanism, given the elimination of this practice.

    We absolutely do have at least these two weak links now: Close Rx monitoring of maintenance drugs, and diligent observation of new prescriptions. A serious improvement in both protocols would improve patient care while lowering overall pharmaceutical expense to both plans and patients.

    Electronic medical records requirements have greatly improved information transfer among medical providers, including Rx histories. All this data compilation is significantly useful–if queried. Patients must also become more responsible in advocating for their own care, certainly with respect to pharmaceutical issues noted by Lowell J. Anderson.

  3. Submitted by Sandi Sherman on 05/04/2016 - 10:25 am.

    Alternatives to narcotics.

    When will the medical profession get serious about pain research and treatment? Millions of people suffer from chronic pain and many become addicted to pain medication, because doctors have no idea what else to offer. I can’ tell you how many times I have been prescribed narcotics for pains even when I tell docs I don’t tolerate them well. Alternative treatments to manage pain are generally not covered by health insurance.

    I can’t tell you how many bottles of opioids I have from surgeries that I have barely used over the years. I agree with the idea on dosing, but much more needs to be done to find and finance alternatives to drugs for chronic pain.

  4. Submitted by Steve Ariens on 05/04/2016 - 03:17 pm.

    opioid addiction epidemic

    It is too bad that Pharmacist Anderson focuses the factoids that the DEA/CDC and other parts of the Federal alphabet of agencies routinely regurgitates.
    There is an estimated 106 chronic pain pts and for the last 100 yrs we have had between 1%-2% of our population abusing some substance – other than the drugs Alcohol & Tobacco/Nicotine – As some are finally recognizing that those who are abusing some opiates are suffering from addictive personality disorders, but since our judicial system – with no medical education – in 1917 declared that those abusing opiates were not suffering from a DISEASE…but… were committing a CRIME and it was made illegal for a doctor to treat/maintain a opiate addict. When you give our judicial system the authority to treat a medical disease.. you get a judicial treatment – INCARCERATION.. I have yet to see a study that suggests that incarceration is an effective treatment for mental health issues… yet 100 yrs later, we continue to apply the very same therapy to those with mental health issues.
    That 257 million opiate Rxs is a awful BIG NUMBER… but when you extrapolate that number into real life figures.. you will get this.. “best practices” in treating chronic pain pts recommends a long acting opiate and short acting opiate for break thru pain.. the typical opiate Rx is for 28-30 days supply.. that would mean that abt 10-11 million chronic pain pts would get recommended therapy… that would also mean that some 90 odd million of chronic pain pts would not get ANY THERAPY nor would anyone with ACUTE PAIN.. get ANY THERAPY..
    What is more scary all of those with chronic or acute pain NOT GETTING ANY THERAPY or 257 million opiate Rxs being filled every year ?
    Lets look at what kills us every year:
    450,000 die from use/abuse of Tobacco/Nicotine
    400,000 die from medical errors
    85,000 die from use/abuse of Alcohol
    50,000 die from suicide .. and we have 1,000,000 unsuccessful attempts
    45,000 die from hospital/nursing home acquired MRSA & C-Dif staff won’t follow aseptic policy
    23,000 from infections resistant to all antibiotics because of our indiscriminate use of antibiotics
    16,000 from Rx opiates – most who do not have a legal Rx for the medication
    8,000 from Heroin
    abt ONE MILLION preventable deaths.. before opiate related deaths that never reach the front page media….and we have spend 1.5 TRILLION since the war on drugs was declared in 1970 with The Controlled Substance Act and we continue to spend 51 billion annually… As a society, we continue to focus on denying therapy to those with chronic pain issues while those who have chosen to self medicate the monkeys on their back and/or demons in the their head with some illegal substance… and whose numbers -as a percent of our population – have not varied for abt ONE HUNDRED YEARS …

  5. Submitted by Carrie Preston on 05/08/2016 - 03:50 pm.

    NSAIDS

    I have torn menisci in both knees. My Ortho says to just “tough it out”. He only prescribes opioids for cancer/surgery patients. The amount of Tylenol, Advil and Aleve he suggests I take is stunning and my stomach absolutely cannot tolerate it.

    Give me opioids any day of the week over NSAIDS.

    He is treating my knees but not my pain.

    With all the electronic data mining, I don’t understand why he cannot prescribe an opioid for me and monitor my progress if he is worried about me becoming addicted.

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