Will Massachusetts’ proposed 3‑day opioid limit work?
Monday, October 19, 2015
In a culture that is facing unprecedented numbers of opioid overdoses and death, new ideas to stem the epidemic are sorely needed. Well, Gov. Charlie Baker of Massachusetts has decided to propose something new.
According to a Boston Globe story, Baker is proposing legislation that "would limit practitioners to prescribing no more than a 72-hour supply of opioids to patients the first time they prescribe an opioid to them, with exceptions only for certain limited emergencies."
The basis for this suggestion stems from the notion that the downward spiral of drug addiction often begins with an entirely innocent prescription for acute pain. The pain might be from an injury, a surgery or a dental procedure.
That patient (let's call her "Jane") is supposedly given far more opioids than is reasonable to manage this short-term pain (by the way, how much is that?). Jane fills the prescription. Jane gets addicted. And now Jane is hopelessly trapped in her addiction, and this opens the door to other terrible pursuits such as heroin, drug diversion and sometimes even death.
As a pharmacist, I do have a level of sympathy for politicians such as Baker. I believe he, and many others, sincerely want to propose solutions that will really help. Unfortunately, their policy ideas are only as good as the information they receive. And in this case the information they are receiving is terribly skewed.
The problem is "Jane" doesn’t exist. Jane is a convenient and comfortable idea. Yes, it is conceivable that someone who took a small supply of narcotic simply for acute pain actually got addicted. But it would be rare.
The fact is hundreds upon thousands of patients are prescribed opioids every day, and only a small percentage of them are abusing the medication. There are plenty of studies that show the opioid addiction problem begins not with an innocent prescription for legitimate pain, but by theft or purchase with the overt intention of recreational use of the opioids, alcohol or illegal drugs.
Here is where we really need to intervene and offer hope and help to our fellow citizens.
Do the research. When does the spiral of addiction and abuse typically begin? It begins long before any of these individuals were ever prescribed a controlled substance for legitimate pain.
According to information from the National Center on Addiction and Substance Abuse (CASA) "addiction is disease with adolescent origins." While it is possible for people to begin their addiction problem later in life, we know it is far more likely if they have developed problems with substances before.
The simple fact is that some people are prone to addiction — either biologically, emotionally or socially — while others are not. Solutions that treat everyone the same or that think we can fix the problem by artificial limits on first fills are frankly nothing more than political maneuvers that garner publicity without progress.
A three-day limit on first fills for opioid narcotics will simply add a layer of legislation without any tangible impact on public safety. It will greatly inconvenience legitimate post-surgical patients, particularly senior citizens who have the lowest rates of abuse, but often need opioids to manage pain related to common procedures such as hip or knee surgeries. The law boasts big things, but in the words of Shakespeare, it is full of "sound and fury, signifying nothing."
Do you really want to fix the opioid problem in Massachusetts, Gov. Baker?
Here's an idea: Talk to real pharmacists. Talk to working, front-line, filling-prescriptions-for-these-drugs everyday pharmacists. Take a look at the top 30 narcotic-filling pharmacies in the state. Talk with a representation of staff pharmacists from these stores.
Ask them about the pressures they are under when filling prescriptions every day. Ask them if they typically have time to check the PMP (prescription monitoring program) for every fill. Ask them if they know about shady physicians or patients who regularly fill narcotics.
Here's an idea: Develop a simple online reporting system where pharmacists can report suspicious activity from patients or prescribers. When multiple pharmacists have reported the same individual — do something about it.
Here's another idea: Trace the narcotics involved (whenever possible) for every reported overdose back to the prescriber and pharmacist and notify them. I don't know about physicians, but pharmacists never hear about prescriptions they have dispensed that ended up being diverted or abused. Never. So guess what? Nobody thinks they are the problem.
The bottom line is this: Look to your real-life dispensing pharmacists for some help in solving this part of the problem. No one profession can fix it alone. We need cooperation from law enforcement, legislators, physicians, nurses, health institutions, social workers and many more. But a failure to talk to and engage with real-life practicing pharmacists is simply inexcusable.
Pharmacists see what is going on. Why not ask them about it? That might be a new idea worth thinking about.
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