Consumers sometimes report to Institute for Safe Medication Practices (ISMP) that their pharmacy dispensed fewer tablets or capsules than prescribed when filling their prescriptions. Many of the complaints involve opioids. When reporting the shortfall, consumers report that pharmacists often suspect that patients or someone in their home removed some tablets for themselves or to sell. Patients tend to say the same about the pharmacy staff. 

In truth, although not the only problem, prescription drug-abusing adults and students, including middle-school and high-school students, do sometimes obtain drugs from a family member’s medicine cabinet. At the same time, research shows that diversion through “shorting” (undercounting) and pilferage by pharmacists and pharmacy staff also takes place.1 For example, an April 2016 story in The Columbus Dispatch described multiple examples of diversion in various settings, including community pharmacies.2 In one example, a pharmacy technician in a community pharmacy regularly dropped vials of oxyCODONE on the floor at the point of sale and would keep a few tablets for herself when she bent down to pick up a vial.

The current practice of dispensing controlled substances as loose tablets or capsules in a vial makes it easy to divert a few tablets at a time. Control is better outside the United States where most drugs, including opioids, are dispensed using a packaging system called “patient packs” or “unit of use” (a sealed patient package containing a typically prescribed quantity). Manufacturers, clinicians, pharmacists, and computer-system vendors abroad have worked together to standardize the available quantities. Foreign pharmacists ISMP speaks with are happy to not count tablets, and they say they rarely hear from patients about missing doses. The manufacturer’s package provides tablets enclosed in individual blisters, often in strips of 10 and on flat cards that take up little space. The drugs are sold in sealed containers that hold typically required quantities. The slot for each tablet is numbered so the quantity can be seen at a glance, even if the box has been opened. In the United States, patient packs are available for certain controlled drugs but are rarely used in the community setting.

If patient packs were used for oral opioids in the United States, most of the count disputes would be eliminated, and drugs would be more difficult to divert. Patients and pharmacists would be able to readily identify the quantity of tablets being dispensed, and patients could be asked to acknowledge the quantity at the point of sale. Such packaging could also help consumers detect diversion at home because the quantity remaining would be readily identifiable. Unit-of-use packaging can also help spot a dispensing error, as each unit-dose package in a blister or strip has the drug name and strength printed on it.

There may be several reasons why US outpatient prescribers and pharmacies have not embraced the use of patient packs. For example, the packs often cost more per dose. In addition, prescribers would also have to prescribe only the quantities available in patient packs, and insurance companies would need to cover the packs, as well as the various day supplies that would match the quantities available and the frequency of administration. The packs may also take up more storage space, and individual blisters may be difficult to open. 

However, given the opioid abuse crisis, it is worth investigating packaging and dispensing changes that might help reduce diversion.
 
Dr. Gaunt is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/Ambulatory Care Edition.