CVS pharmacies announced today that they will no longer fill prescriptions for opioids for more than one week without a repeat prescription from the physician. This will affect their nearly 100,000 Caremark members and they will counsel others as well.
NBC News TV, September 22, 2017
Of course the best treatment is prevention, which means decreasing the availability or prescriptions for opioids in the first place. The Food and Drug Administration (FDA) has produced guidelines for effective pharmacologic use of opiates, which include the identification of persons at risk, assessing a patient’s benefit vs. risk, and developing and using tools to decrease risks of opiate prescription, including contracts for pain management and standards of required 30-day physician visits before new prescriptions can be refilled.
Prevention strategies include:
Patient education regarding the use of opiates, and truly all prescription medications, is essential for them to understand the need for the drug, its side effects and adverse effects. An additional pain contract, which outlines the parameters for the use of the drug, may be included with the patient education. Especially when used for chronic pain management, patients should be partners with the prescriber to outline when the drug will be used and for how long.
Prescription monitoring programs include detection systems in pharmacies and the local district that identify patients who have filled a narcotic prescription. In many states, photo ID is already required for the purchase of cigarettes or alcohol and could become a beginning point to dissuade unauthorized and high-frequency prescription use. According to the National Alliance for Model State Drug Laws (NAMSDL, 2017), currently 85% of states require ID for narcotic prescription use. Some drugstores even run the name of a client picking up a narcotic prescription through a drug monitoring data system for alerts. The challenge is for busy pharmacists to take the time to use the monitoring system and for all of us to be patient as the process is completed.
Possible red flags that could lead to prescription denial:
Another strategy includes receiving prior authorization before opiates can be filled. In 2007 the FDA passed an amendment to create a patient registry for opioids. In 2012 Blue Cross Blue Shield began to require prior authorization for more than a one-month supply of opioids in a two-month period. By this simple process alone, in the state of Massachusetts, the number of opioid prescriptions was decreased by more than 6,500,000 pills in one year (Boston Globe, 2012).
Safe disposal of opioids is a challenging issue because many people believe that flushing them down the toilet is appropriate, which it is not. Public education and awareness programs must also include safe medication disposal, such as mixing with used coffee grounds, dirt, or kitty litter and placing in a sealed container to dispose of in the garbage. Used opioid patches should be folded in half on the sticky sides and disposed of in a sealed container in the garbage.
Several screening tools are available to help clinicians identify when a patient taking opioids may be experiencing dependence or addiction.
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs” (SAMHSA, 2016). The SBIRT model was inspired by a recommendation from the Institute of Medicine to increase community-based screening for health risk behaviors, including substance use.
SBIRT is an early and brief intervention of 15 to 30 minutes and billable to Medicare/Medicaid. The screening and referral to treatment includes a patient encounter, history, physical examination, clinical diagnosis, and plan for care specific to the concern of substance abuse (other than for those patients already identified with severe substance abuse). The SBIRT screening tool can be as simple as asking several key questions of patients receiving narcotics and opioids at every doctor’s office visit.
The Opioid Risk Tool is another brief screening tool of questions to help identify a patient at increased risk for dependence and abuse. Currently no one tool has been identified to be better than any others, nor is any one tool sufficient to identify drug behaviors of chronic pain patients using opioids (Turk et al., 2008).
Test Your Knowledge
What is the SBIRT screening tool?
Apply Your Knowledge
In the case presented at the beginning of this course, what steps could have been done to help identify the patient as at risk for opioid addiction and to avoid the overdose?
YouTube: The Clinical Assessment of Substance Use Disorders—Role Modeling the Initial Visit
YouTube: The SBIRT Process (role model)
YouTube: The SBIRT Audit Screening Questions
Article: Strategies to Prevent Opioid Misuse, Abuse, and Diversion that May Also Reduce the Associated Costs