Opioids — America in Pain
The Crisis — Part 1
Providers wrote nearly a quarter of a billion opioid prescriptions in 2013, which is enough for every American adult to have their own bottle of pills. It’s nearly 2018, just where are we headed? According to the National Institute on Drug Abuse in 2017, more than 90 Americans die every day after overdosing on opioids. A pandemic is on the rise in the United States. How did we get here? And what can we as prescribers, pharmacists and service providers do in this raging battle on the street and in the home with opioid addiction?
In the late 1990s, opioid pain medication prescriptions were launched into the hands of patients by prescribers after the pharmaceutical companies reassured the medical community that patients would not become addicted. In turn, the opioid runaway train departed on the rails of misuse before we had the chance to become aware of the highly addictive nature of these substances. Therefore, the healthcare ecosystem has been wildly affected by the infiltration of opioids.
Timeline Leading to Opioid Catastrophe:
- 1996: The American Pain Society trademarked the slogan “Pain: The Fifth Vital Sign.” Purdue Pharma released OxyContin, the most widely used narcotic pain killer today.• 1998: The Veterans Health Administration and the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) both claimed pain as “The Fifth Vital Sign.”• Late 1990s: Groups such as the American Pain Foundation urged the tackling of untreated pain. Physicians were falsely educated that the risk of opioid addiction was less than 1%.
- 1998: The Federation of State Medical Boards released a recommended policy reassuring doctors that they would not face regulatory action for prescribing large amounts of narcotics.
- 2001: JCAHO issued new standards telling hospitals to ask patients regularly about pain and to make treating it a priority. JCAHO published a guide sponsored by Purdue Pharma that stated “Some clinicians have inaccurate and exaggerated concerns about addiction, tolerance, and risk of death. This attitude prevails despite the fact that there is no evidence that addiction is a significant issue when persons are given opioids for pain control.”
- 2004: The Federation of State Medical Boards called on the state medical boards to make under-treatment of pain punishable for the first time.
- 2007: Purdue Pharma and three executives pleaded guilty to misbranding of the drugs as less addictive and less subject to abuse than other pain medications. They paid $635 million in fines.
- 2010: Opioid sales were four times those in 1999.
- 2012: 259 million prescriptions were written for opioids. Sales of opioids total more than $9 billion per year.
- 2013: Opioid overdose deaths surpass car accidents as a leading cause of accidental death.
- 2016: 1.4 million patients had an opioid dependency diagnosis. (This number does not account for the hundreds of thousands more fighting addictions while on Medicaid, Medicare, or uninsured.)
- 2017: Lawsuits against Purdue Pharma and other drug manufacturers of opioids continue. A pandemic ensues.
What creates the addiction? Opiates are not new. Mesopotamia first cultivated opium from poppies three and a half millennia BC, and humans have been questing after it ever since. Opium and all its derivations exert their effect through opiate receptors in our central nervous system. They possess the ability to produce extreme euphoria, such as an athlete derives from a runners high and mating behaviors create sexual arousal. Through opioid pharmaceuticals a person can experience instantaneous euphoria without delay of gratification, meaning they don’t have to come upon injury or elicit any behavior. All they have to do is inject the substance or pop the pill, and they are hook, line, and sinker deep in opioid waters.
There are multiple opioids to explore. Opiates can be naturally occurring or synthetic. Morphine and Codeine are extracted naturally from the poppy and their derivatives are Hydromorphone (Dilaudid) and Hydrocodone (Vicodin). Meperidine (Demerol) and Fentanyl and Oxycodone (OxyContin) are examples of the synthetic narcotics.
Fentanyl is a synthetic opiate narcotic that was clinically introduced in the1960s. It has a broad therapeutic range and is a safe drug when administered by trained practitioners, anesthesia providers, PACU nurses, and other licensed medical practitioners familiar with the drug. Fentanyl is also an extremely potent narcotic. 100 micrograms of Fentanyl have the analgesic equivalence of approximately 10 milligrams of Morphine intravenous. It’s the potency and the rapidity with which it acts upon the brain, producing a greater rush and extreme euphoria, that hooks the patient or street user and reels them back for more. What the user doesn’t understand or care to know, once the addiction has overtaken them, is that such potency can induce respiratory suppression, somnolence, and central nervous system depression. Without the benefit of resuscitation, in some circumstances, this may lead to death in an overdose.
The Prescriber’s Nightmare.
With the advent of the Fifth Vital Sign, mandating that each patient’s pain be noted and treated with the expectation of a pain-free result, pushed the prescribing physician up against a wall. They were caught between the new standards set by governing agents and the potentials lurking in the back of their minds. This new governing thought set forth the idea – if a patient was experiencing pain then he was being under-treated. Yet, there is no way to measure a patient’s pain like there is blood pressure. It’s all subjective. What was a doc to do? Sometimes the patient returns with increased pain, hence, the dosage gets increased. And the addicted patient learns his way around the opioid ring, figuring out how to use multiple doctors to obtain multiple prescriptions. The opioid frenzy sent patients wanting more and more euphoria without needing any analgesic effect. Over time, this added a new form of assessment for the doctor to now monitor drug-seeking behaviors with his opioid patients.
A huge issue for the prescriber is theft. People such as other family members and friends and the black market are taking the drugs. Acquiring prescriptions to sell them on the streets, faking increases in pain to get larger doses, saying “the medicine is no longer working so can I have a different one that’s stronger” are diversion tactics that raise the red flag for the physician on the front line of this drug war on American soil.
The Pharmacist. The Cop.
The pharmacist in the healthcare ecosystem has become a drug cop policing prescriptions when necessary. There are the patients in dire need of pain relief and there are those addicted to opioids that will stop at nothing to get a prescription filled for themselves or the thriving black market. The pharmacist is on the front line in this battle too. The patient may be standing there with a prescription in hand, but it is the pharmacist who must make that final decision to fill or not to fill.
The pharmacist is armed from state to state with a PDMP (prescription drug monitoring program) to support patients and healthcare providers in the safe and effective use of prescription drugs, including opioids. The PDMP’s goal is to securely collect and store information about drugs that contain controlled substances as facilities dispense them to patients. The PDMP tracks the prescribing and dispensing of controlled prescription medications. Although this tool has proven useful in preventing drug diversion, it is only useful for healthcare practitioners who use the system correctly prior to prescribing and dispensing. Using this tool consistently by both pharmacists and physicians is crucial.
Where is the Government?
The government has been scrambling to set forth guidelines and parameters for controlling what has exploded out of control. There are guidelines set forth by the Center for Disease Control and Prevention for the control of chronic pain. Yet, the avalanche is already in motion and gaining momentum down the mountain. Time will tell where the government will weigh in, and the clock is ticking.
A Solution in the Eye of the Storm.
KeyCentrix has been working to prevent opioid abuse. The NewLeafRx pharmacy management system by KeyCentrix is designed to assist with this specialty need. Our solution helps curtail the chaos a pharmacist faces in the eye of the opioid storm. NewLeafRx pharmacy management software has a built-in understanding, through its robust configurations, for enforcing the rules surrounding controlled substances based on Drug Class. It has been helping pharmacies meet compliance regulations to control opioid abuse. With the increase in e-prescribing for controlled substances, fraudulent prescription fills can be avoided. NewLeafRx’s reporting abilities, at the click of a finger, can evaluate the amount of controlled substances being dispensed, track them, appropriately dispense, and maintain records on multiple levels of the pharmacy’s controlled substances. Inventory Management within NewLeafRx perpetually manages a pharmacy’s controlled substance NDC that should be stocked and dispensed. Also, the pharmacy now has the ability to only dispense manufacturers that are compliant in adhering to the reduction of inappropriate use of controlled substances. The system is able to group similar inventory brands together and recommend the preferred brand to be stocked. This affords the pharmacy an opportunity to dispense a generic brand, reducing the likelihood for the controlled substance to be abused versus used as directed.
NewLeafRx is built for Managing Controlled Substances:
- PMP Reporting specific to the requirements of each State Board of Pharmacy
- E-prescribing for controlled substance
- DEA Number required and included to fill script
- Electronic signature capable of tracking exactly who picked up the script
- Controlled Substance Report for Class 2, Class 3, Class 4 & Class 5 drugs
- Drug Velocity Report (evaluates controlled substance usage for a given time period)
- Differentiating Fill Numbers
- Effective Date option on Fill Form for future dated prescriptions (avoids misplacing or miss-filling scripts that have a different effective date than the one written.)
- Scheduled Prescription ID required (when applicable)
- Configuration for Rx Reassignment of partial fill, transfers, and max number of refills for an allowed scheduled drug class
- Configuration of which scheduled drug class requires a driver’s license and a SSN to be stored on the patient profile
Further Recommendations for Pharmacies
- Use features in the pharmacy system in reporting PMP
- Fill only prescriptions that come from a prescriber with a valid DEA number
- Stock generic white pills rather than the pills that have high street value
- Utilize e-prescribing for controlled substance to minimize the amount of fraudulent prescriptions (EPCS)
- Stay compliant with the dispensing percentage allowable for controlled substance
Systems like NewLeafRx will help prevent the increase of opioid abuse in the United States. It arms pharmacists everywhere with the tools needed to reduce the opioid pandemic plaguing Americans as the battle wages on to save lives.
Watch for KeyCentrix’s upcoming blogs on medical marijuana and continued updates on the opioid crisis. Share your thoughts and questions here on this topic. And let us know what you would like to read more about in our blogs!