The pain-med choke point

Steve AriensIn December, NCPA sent out a survey asking pharmacists whether they are having increasing difficulty acquiring controlled medications. While the survey was still open (it closed December 18, 2013), NCPA released some early comments.

It prefaced them with a statement that said in part, “For some time NCPA has been aware and working to resolve the issue of an increasing number of pharmacies being unable to procure controlled substances to fill prescriptions. This, of course, is a great concern not only for our members but for patients who need these medications most often to treat acute or chronic pain. To better understand the prevalence of this situation and its impact on patient access, NCPA’s most recent action was to send a member survey you should have received.”

Bulletins from the front lines

In that follow-up e-mail, NCPA went on to say that it had received 120 responses “in the first hour” of the survey. Among them were these:

- “We turn away patients on a daily basis that I am sure are legitimate patients with legitimate prescriptions with legitimate issues requiring pain management. I am one in a long line of pharmacies that turns these patients away because of the limits on what I can dispense monthly.”

- ŸŸ“…Recently I’m very concerned that, as a result of taking on patients who are opiate refugees from other pharmacies, we’ve elevated our visibility with our wholesaler and will soon be ‘whammied’ with more stringent monthly allotments.”

- “We have recently been inspected by our wholesaler. This is an effort to make sure that we are dispensing appropriately. The problem is they ask for statistics such as percentage of controls versus total Rx volume. These numbers need to be adjusted as our volume of maintenance medications continues to be reduced by mandatory mail order programs.”

- “We were informed by our [X] wholesale rep on Oct. 29 that our hydrocodone percentage was above their ‘average’ and that our purchases would be capped beginning Nov. 1. They would not give us the amount at which our purchases would be capped or how the ‘percentage’ was calculated. The local rep would only say that the DEA [Drug Enforcement Administration] was mandating that they decrease the amount of hydrocodone they were shipping and that their new practices were a result of the DEA actions.”

- “The suppliers are hesitant to give us guidance. When they do, it changes on the fly. They are terrified of the DEA.”

- “We cannot obtain any alprazolam after about 2 weeks into each month and cannot obtain hydrocodone by the last week of the month. A competing pharmacy cannot obtain oxycodone after about 10 days into the month.”

NCPA went on to say, “What makes this issue complex is that there is a prescription drug abuse crisis in this country that has to be addressed. DEA seems to have decided that the wholesalers are the choke point (a cynic might add that they also have the deep pockets to pay huge fines levied by the DEA).”

What kind of system?

So, how many other disease states can you name, in response to which our government and our society discourage healthcare professionals from providing adequate/aggressive therapy for a patient’s medical issues?

Imagine what would happen if prescribers allowed their patients’ blood sugar to be in the 250 + range, or their blood pressure > 200/100 and/or lipid levels at 250-300 or more. Someone would throw the book at them.

But leave a patient suffering from untreated or undertreated pain and they get “two thumbs up.”

What kind of system actively sets out to increase the hardship and suffering of others? What kind of country?

Leave ’em to suffer

Chances are, if you don’t already know someone who is suffering from chronic pain, you eventually will.

If the decisions emanating from the DEA have not impacted you, someone you know, someone you love, or your business, rest assured that they eventually will.

We treat our beloved pets better than we do fellow human beings. If our pets become ill and are “suffering” … if their illness can’t be resolved and their suffering stopped ... we have the option to “put them down.” This breaks your heart, but you do what is best for a suffering pet.

But when it comes to chronic pain patients, our society seems hellbent on letting those poor people just suffer, when there are options that would address their chronic pain. For what other disease state does our society discourage healthcare providers from providing adequate/aggressive therapy/treatment?

 It is estimated that >50% of individuals labeled “dead from a drug overdose” are really suicides - chronic pain patients who are receiving only “token doses” of opiates to treat their pain.

From awards for pain management to war on pain patients

On this subject, I received the following comment at my blog:

In 2012 I received our state pharmacy association’s Innovative Pharmacist of the Year award for my work in pain management. Just three weeks after we were named as a quarter finalist for our wholesaler’s pharmacy of the year award for our work in the pain management field, our pharmacy was cut off from scheduled medication without warning or reason.

In our semirural area, there were no other pharmacies that could take in our pain patients. We had two reported suicides, one medical death we believe was related, multiple hospice admits, multiple ER admits, some hospital admissions, and lot of lost function and quality of life.

Now we hear that restrictions are growing. Pharmacies that were unaffected by the summer controlled substance cutbacks began to experience cutbacks in the fall.

Just look at the numbers

So here are the statistics:

Eight million chronic pain patients are treated with opiate-based medication safely and effectively every single day in this country.

About 16,000 people die each year from opiate overdose. It is believed that most of them were recreational users. A large portion of those had their medication dispensed directly from the “physician” at a clinic. (Florida no longer allows this.)

About 16,000 people die each year from NSAID use. It is believed that they are not recreational NSAID users.

The CDC announced this year that about 23,000 people die each year from the consequences of antibiotic misuse.

I believe the above speaks to the need for the work of local pharmacists, who have a relationship with their patients and the time to counsel them and monitor their medication use.  

I have more than just a rant; I have a solution. Go to www.paintrac.com and look at the CSAPP Controlled Substance Advanced Practice Pharmacy registration model I propose for maintaining patient access to care. It is a workable solution; we’ve used it daily for 10 years.

I will post updates on this subject at my blog. If you have a comment or suggestion, go to www.pharmaciststeve.com.

Steve Ariens is National Public Relations Director for The Pharmacy Alliance (www.thepharmacyalliance.com). You can e-mail him at steve@steveariens.com or check out his blog, pharmacist steve (www.pharmaciststeve.com/).