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 use of opiates
- Pain contract signed by patient to agree to terms of drug use
- Prescription monitoring programs to detect multiple use of pharmacies and physicians for opiates
- Detection of inappropriate prescribing of opioids
- Photo identification to pick up opioid prescriptions
- Urine toxicology screening for employees
- Safe disposal of unused opioids
- Referrals to pain and addiction specialists
- Use of semi-synthetic opioid alternatives
Patient education regarding the use of opiates, and actually all prescription medications, is essential for them to understand the need for the drug, its side effects, and adverse effects. A 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.
Photo ID for prescriptions?
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:
- A pain medication not previously filled by the pharmacy
- A “new” doctor writing a prescription for the same pain medication
- A doctor writing a prescription who is not in a “reasonable geographic location” near the pharmacy
- A patient paying for a prescription in cash
- A patient seeking an early refill of a prescription
- A patient seeking an “excessive” number of pills
- A patient taking the same pain medication for more than 6 months
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). In 2018, CVS Caremark introduced limits on opioid prescriptions based on guidelines that aligned with the CDC’s Guidelines for Prescribing Opioids for Chronic Pain. Some insurance plans have discontinued coverage for certain addictive opioids in favor of drugs that have a lower risk of abuse; for example, Blue Shield Blue Cross no longer covers OxyContin in Alabama and Tennessee as of January 1, 2019 (Demko, 2019; AP, 2018).
To combat the prescription drug overdose epidemic, many states have enacted laws that set time or dosage limits on the prescribing or dispensing of controlled substances. One main category of prescription drug limit laws sets forth time limits (hours’ or days’ supply) to the supply of prescription drugs. These tim- limit laws can be further classified by their applicability to certain drugs, certain populations or certain situations.
Some states set time limits for prescription drug refills. Another category of prescription drug limit laws regards the dosage of prescription drugs. Although state laws are commonly used to prevent injuries and their benefits have been demonstrated for a variety of injury types, there is little information on the effectiveness of state statutes and regulations designed to prevent prescription drug abuse and diversion (CDC, Public Health Law, 2015).
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.
The DEA has strict regulations for drug take-back programs, including National Prescription Drug Take Back Days. The Seventeenth National Take Back Day, April 27, 2019, collected 937,443 pounds (468.72 tons) of prescription drugs nationwide (DEA, 2019).
Screening Tools for Addiction
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 and HSRA, 2019). 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.
Opioid Risk Tool and Pain Medication Questionnaire
The Opioid Risk Tool and Pain Medication Questionnaire (PMQ are other brief screening tools 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 (Klimas et al., 2019).
Test Your Knowledge
What is the SBIRT screening tool?
- A form completed to assess for risk for drug abuse.
- A brief intervention billable to Medicare/Medicaid.
- Used to admit a patient to a rehab facility for drug abuse.
- The history and physical used to assess patients for drug abuse.
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?
The SBIRT Process (role model) [7:57]