Ms. Heinze is a freelance writer based in Vancouver, British Columbia.
Few would disagree that pharmacists want the prescriptions they are filling to be used properly. With the pressures associated with the nation’s health care costs on the rise and the emphasis on medication therapy management, the profession is playing a larger role in counseling patients not only to take their medicine, but to do so according to the instructions—and if they are not being followed, to play a part in finding out why. Another element is safety: what physicians prescribe—or even what patients buy over-thecounter—can be harmful if misused, or in the worst cases, abused.
According to Richard Logan, PharmD, a pharmacist at L&S Pharmacy in Charleston, Missouri, and a police officer with the Mississippi County Sheriff’s Department, prescription abuse cannot be linked to one specific socioeconomic demographic. “The problem of prescription drug abuse covers all ages, sexes, and race—it makes no difference,” he said. “It is a universal problem, and because of that, there are no hard and fast rules to pick out the person that is the abuser.”
This means that the medical community must be on the lookout at all times, starting with an emphasis on the relationship between the patient and those providing their health care. “Pharmacists are charged by education, training, and oath to ensure the safe and sane use of drug products in our patients,” Logan said. “When a patient sees a physician, the physician has a duty of care that he must fulfill.”
In order to prescribe opioids and controlled substances, he adds, there must be a true physician–patient relationship. “If every step in the patient care process has not been undertaken by anyone in the chain, it is our duty to not fill that prescription and, depending on the circumstances, proceed from there.”
A number of signs hint at prescription abuse: requests for early refills, patients who seem to be overly knowledgeable about the drugs they are taking, and an insistence on becoming extremely familiar with the pharmacist are good indicators. Some patients will try to alter prescriptions outright, noted Lauren S. Schlesselman, PharmD, assistant clinical professor of pharmacy practice at the University of Connecticut at Storrs. “There might be a mark from a different pen: the doctor might have written a prescription for 80 tablets, and there is a “1” that was written in an ink that wasn’t quite the same color,” she illustrated. Another method is pharmacy-hopping: a patient fills a prescription at one pharmacy one day, and then tries to do the same at another outlet the next. These individuals often request to pay for the order in cash, rather than having it run through the insurance system.
Schlesselman notes that some patients will go so far as to attempt to strong-arm the pharmacist into filling a prescription that does not mandate refills. Others may insist that only one narcotic works—which may be true in some instances, she admits, but not always. Then there are the most obvious signs of abuse, such as track marks, pinpoint eyes, and slurred speech.
In many pharmacies, technicians are charged with receiving prescriptions and entering them into the computer; then, either the pharmacist or technician will fill the order, and the pharmacist will double-check it before handing it over to the patient. No matter the workflow process, when a prescription for a narcotic comes in, it warrants some attention. “Even when the technicians are entering the prescriptions into the system, they can look at the profile and see how often this patient is filling prescriptions for abusable substances,” Schlesselman said.
Although pharmacy staff should receive the training necessary to identify prescription abuse, Kristen Binaso, media advisor and director of corporate alliances at the American Pharmacists Association in Washington, DC, underlines that the buck stops with the pharmacist. “Ultimately, when that prescription is given to the patient, it is the pharmacist’s responsibility to counsel that patient,” she said. “The pharmacist needs to be out there so that they can say to the patient, ‘I am going to go over some important things about this medicine.’” Despite the increasing demand on the pharmacist’s schedule, it is too important not to make the time for this, she maintains. “When it comes to someone’s risk and benefits, we shouldn’t be too busy.”
When suspicion is aroused surrounding a specific prescription, the first step is to contact the prescribing doctor. Oftentimes, it is discovered that the physician is not aware that the patient has been receiving prescriptions for controlled substances from practitioners—and even if that is not the case, the pharmacist should put in a call anyway. “I still want to call and find out what is going on,” Schlesselman said. “The pharmacist should be in the loop about what is going on with the patient’s care, and the doctor may be able to say, ‘this person has a lot of pain from this injury or this type of chronic disease.’” The physician may not know what is going on either, however. “They may not realize that the patient is going to one doctor for a controlled substance for cough, and they are going to them for pain.”
What happens next varies, depending on the circumstances. Some pharmacists will simply refuse to fill the prescription, write “void” across it, and hand it back to the patient with an explanation as to why the order was refused, whereas others will contact the police. Regardless, it is necessary to work with other health care providers in the community. “You need to keep those lines of communication open and not be afraid to bring it up,” Binaso said. “Not everyone is going to be open to it, but if they choose to act on that information—and you would hope that they would—that is their choice. The fact is that my role, as a health care provider, was to take it up with them.”
In April 2008, the National Community Pharmacists Association (NCPA) launched the “Protect Your Pharmacy Now!” initiative to help its members deal with the issue of pharmacy crime, including prescription abuse. John Norton, public relations manager at the NCPA, notes that this spring, the association added a prescription disposal program as well. “[It] helps members set up programs that will keep their patients from keeping expired and unused drugs in their cabinets that can be abused, and avoid simply flushing them down the toilet where they can contaminate our drinking water,” he explained.
As the FDA investigates pain medications, Binaso believes that the discussion on risk management programs will move to the forefront. These initiatives may involve a patient registry or contracts between medical practitioners and their patients that spell out how medications should be used and that require, under signature, patient compliance.
“Part of the discussion is covering what kind of pilot programs should be run, because they do not think that the patient understands the risk and benefits, and there is a lot of concern about abuse,” she said. “It is a matter of seeing what is really out there—and I think that is what the FDA is trying to do right now—and then coming up with some pilot programs that can be tested to see if they work.”
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