Although the landscape for the abuse and diversion of pharmaceutical drugs has changed over the years, the same ones seem to still be at the center of the opioid crisis. But pharmacists are in a prime position to offer education and use their training to help fight abuse and diversion.

One recent change is that the number of prescriptions for controlled substances has fallen considerably in the past few years, even while the number of deaths from opioid overdoses has risen. This, of course, is attributable to the influx of heroin and illicit fentanyl into our country. We are also now seeing the abuse of huge amounts of crystal methamphetamine, sometimes with fentanyl added, and the resurgence of cocaine.

This fentanyl/heroin crisis that has killed countless individuals spawned from the reformulation of OxyContin. I saw it happen as the drug was about to go to market in August 2010. We began seeing more heroin come into southwest Ohio. Mexican cartels are not stupid, and they knew that if the reformulation worked, they had a lucrative new market. They took full advantage of this by putting thousands of pounds of heroin on our streets. China primarily fuels the illicit fentanyl trade that enhances heroin to create a better high and the possibility of overdose and death.

Meanwhile, many people have blamed Purdue Pharma for the fentanyl/heroin deaths, theorizing that by successfully reformulating OxyContin, the company caused the problem. This is absurd, as Purdue Pharma spent millions of dollars to make the abused product much less diverted, and their efforts worked. The company’s sales fell, indicating what we knew all along: that the drug was being highly abused while in its original formulation. However, blaming Purdue Pharma for the illicit drug problem makes no sense.

It is heartening to see the CDC relaxing some of its earlier statements concerning the prescribing of controlled substances. Although some drug seekers were certainly deterred because of those earlier statements, I am more concerned that many patients with legitimate pain were denied appropriate medications.

In 2014, hydrocodone combination products were categorized as a schedule II controlled substance, and the sales of this drug declined. Yet it is still often abused. Oxycodone IR 30 mg is the most sought-after prescription drug for heavy abusers and has been the mainstay of pill mills in the United States.

We will likely never eliminate pill mills entirely, but states have made great strides in the past 10 years, most notably Florida. Ohio drug seekers and other Midwesterners were flocking to Florida to take advantage of the many pill mills, most trying to disguise themselves as legitimate pain management offices. Law enforcement agencies and pharmacies in Ohio were scrambling to determine whether the drugs or prescriptions were legitimately in the possession of these travelers. In most cases, our hands were tied, as the drugs had been prescribed by “legitimate” prescribers in Florida. Kudos to Florida law enforcement and regulators for getting a handle on the situation.

Prescription drug abuse is still flourishing but not at the level of the late 1990s to 2010. Alprazolam, hydrocodone, and oxycodone are still often abused. But prescription monitoring programs (PMPs) have better equipped pharmacists and providers to gauge patients’ behavior more accurately and seriously weakened doctor shopping. This could also have reduced the amount of health care fraud, as much of the diversion of pharmaceuticals is related to Medicaid, private insurance, and worker’s compensation. As electronic prescriptions become more commonplace, these, too, will impede those who wish to alter or forge controlled substance prescriptions.

However, addiction is not going away anytime soon, and whether the lure is getting high or making money, it will continue to be a major problem. Fortunately, the use of nasal naloxone has helped to stem the overdose deaths. Adding it to law enforcement’s tool belt saved even more lives because officers often arrive before emergency workers when users are overdosing.

Our nation’s pharmacists are key to reducing prescription drug abuse. By applying common sense when looking at scripts and using their state’s PMPs, pharmacists play a big role in combating pharmaceutical diversion.
 
Cmdr. John Burke is a 40-year veteran of law enforcement, the past president of the National Association of Drug Diversion Investigators, and the president and cofounder of the International Health Facility Diversion Association.