Pharmacies are not the only ones to blame for the opioid epidemic

By Annemarie LePard

Pharmaceutical companies have been blamed and punished for the opioid epidemic for years; but they are not entirely at fault. Physicians, drug manufacturers and pharmacies are all guilty of different kinds of misbehavior.

“The doctor is illegally writing scripts; the drug manufacturer may be hiding information about the negative effects of a drug or may be improperly making it, and then the pharmacy may be either knowingly, or grossly negligently participating in a whole set of transactions,” said New York Assembly Member Richard Gottfried, chair of the committee of health.

Physicians, drug manufacturers and pharmacies are only providing services to what society wants. The crisis stems from a supply and demand for opioid-type drugs in this country.

“If the demand is high then somebody is going to supply it,” said Paul Fisher, professor and vice chair for the department of pharmacology sciences at Stony Brook University. “And, there is enough poverty and enough misery in the world to guarantee that supply will be forthcoming.”

In the late 1990s, pharmaceutical companies “reassured” the medical community that patients would not become addicted to prescription opioid pain relievers, and healthcare providers began to prescribe them at greater rates, according to the National Institute of Drug Abuse.

Now that opioid overdoses have increased and are claiming the lives of thousands of Americans yearly, state governments are introducing new regulations in an attempt to end the epidemic.

These new regulations, however, are causing “a lot of physicians who tend to shy away from using opioids because they are so highly regulated,” according to Fisher. “I was taught as a student never to be afraid of using opioids to treat pain.”

Gottfried agrees there is a fear doctors have when it comes to prescribing controlled substances, but he believes there is another factor that contributes to under-prescribing.

“Some of that is doctors who just don’t appreciate the severity of pain, and there are also doctors who under-prescribe pain medication because they are concerned that a patient might get addicted, or concerned they might get in trouble,” Gottfried said.

Savall Drugs, an independent pharmacy located in Merrick, NY, does not carry opioids regularly because doctors have a “fear of prescribing them.”

“I spoke to the cardiologist across the street and he doesn’t prescribe controlled substances,” said Bob Klieger, the owner of Savall Drugs. “I asked him why, and he said he just gives [his patients] ibuprofen because he doesn’t want the DEA looking through his records.”

According to Fisher, there is a substantial risk that comes along with people overreacting.

“Patients who need pain management of the highest order will have trouble getting it in an attempt to limit illicit opioids,” Fisher said. “These are really useful, really important drugs and it’s a shame that they are so abused, or [have] the potential for abuse.”

The overregulation makes it less and less straightforward for people who actually need controlled substances to live comfortably to obtain them.

“Patients with end stage cancer, with rheumatoid arthritis, to just name a few illnesses, should never wish for death because it hurts so bad,” said Fisher.

Distribution of Controlled Substances

In 2013, New York state approved two laws that would change the distribution of controlled substances in order to reduce “doctor shopping” and “over-prescribing.”

The Prescription Monitoring Program (PMP), formally referred to as the Controlled Substance Information program, gives practitioners “access to review their patients’ recent controlled substance prescription history at any time, therefore, giving [practitioners] more information to exercise their professional judgement in treating their patients,” according to the New York Chapter American College of Physicians.

Practitioners are required to consult the PMP registry in “most cases” prior to prescribing any controlled substance listed in Schedule II, III or IV; however, pharmacists are “not required to consult the registry, as stated by the New York State Department of Health.

“The pharmacist basically relies on the fact that the prescriber, who makes the judgement whether to write a prescription, is required to consult it,” Gottfried said. “The decision whether the information in the database would give you pause about prescribing a controlled substance to a particular patient is really the physician’s judgement, not the pharmacists.”

A pharmacist’s main job is to make sure all prescriptions are dispensed properly, “and that’s why checking the monitoring program is the prescriber’s job, not the pharmacist’s job,” Gottfried said.

In August 2013, the I-STOP Act, also known as the “Internet System for Tracking Over-Prescribing Act,” went into full effect across New York state. The law was put forward to stop “doctor shopping,” according to Amanda Cioffi, a school social worker.

“A lot of people in the early 2000s, were getting prescriptions from three or four doctors in a row; then they were able to go to their pharmacy and get a large amount of controlled substances,” Cioffi said. “And the pharmacy had no way of tracking it, so it’s kind of like they were just dispensing controlled substances to people.”

The I-STOP Act put an end to over-prescribing and enabled doctors and pharmacists to provide prescription medications, and other controlled substances, to patients who truly need them.

“Unfortunately, people fell into heroin,” Cioffi said. “Because [people] could no longer get their prescriptions [filled], they turned to something a lot cheaper.”

The I-STOP Act also eliminates the problem of “stolen and forged prescriptions being used to obtain controlled substances from pharmacies; facilitate prosecutions of crooked doctors; and achieve significant savings for public and private health insurance program,” according to NY Attorney General, Letitia James.

Future Efforts to End the Crisis

Nassau County has filed a lawsuit against more than a dozen drug companies and distributors, health care providers and major companies, including Walmart, CVS and Walgreens, according to News 12 Long Island.

West Islip attorney David Grossman, who represents Island Park, said the suit is for “economic damages related to the opioid crisis,” including the cost to administer emergency response services to overdoses and usage of Narcan.

The trial is expected to start on Jan. 20.

“There are a lot of ill-informed people, ill-informed with respect to the basic science of opioids,” Fisher said. “I am worried that we’re being pressured into making some poor, or ill-informed decisions really quickly without taking the time to understand the problem and all of its ramifications.”

As a pharmacologist, Fisher’s responsibility is to inform and to provide as much accurate information “in what are very large socioeconomic, political decisions” in terms of dealing with controlled substances.

“[For example], in educating physicians, it is [my job] to make them aware of how dangerous opioids are, how valuable they are, how they will lose a valuable tool if they’re not aware of the dangers and handle them accordingly,” Fisher said.

“What is needed is more and better education, and prevention and treatment programs,” said Gottfried.

However, these services cannot be provided to the public when the research conducted cannot guarantee results.

There is limited information on what factors makes these controlled substances addictive. “There is no question there are a lot of scientific issues which make it sensible, but the real answer is, it’s fairly intricate and poorly understood at best,” Fisher said.

With the little knowledge available, “we have no idea how to combat [this crisis],” Fisher said.

Questions to Ask Your Pharmacist — from the Centers for Disease Control and Prevention

-What is this medicine supposed to do?
-How and when should I take it?
-What are possible side effects? What should I do if I get them?
-Should I avoid certain activities, like driving or running?
-Should I avoid certain foods while taking the medicine, such as milk products or grapefruit?
-If I’m having problems with this medicine, when should I call my doctor?
-Can you give me a list of my prescribed medicines?