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Ohio News: Accidental Drug Poisonings in Ohio
Published in the November 2009 Ohio State Board of Pharmacy Newsletter
The Ohio Department of Health (ODH) compiles statistics on many different health-related topics every year and tries to monitor trends so that action can be taken when needed. Just recently, ODH noticed an alarming trend. In 2008, the number of deaths from “accidental” drug overdoses exceeded the number of traffic fatalities in Ohio. While traffic fatalities have remained fairly consistent from year to year, the drug overdose deaths have risen at an alarming rate. A large majority of those overdoses involve prescription opiates, often combined with other drugs or alcohol; however, opiates are appearing as a primary cause in most of these deaths. ODH has become so alarmed by this trend that they have started holding local planning meetings around the state. The first of these meetings was held on October 21, in Portsmouth, OH, where there were more than 120 people present, including doctors, addiction specialists, law enforcement, nurses, pharmacists, and other interested parties. More meetings are being planned.
Pharmacists can, and must, play a role in addressing this epidemic. We have a requirement in our rules (4729-5-20 OAC) that pharmacists must perform prospective drug utilization review on every prescription filled. One part of that prospective review involves detecting and resolving issues relating to overuse and underuse of medications. When a pharmacist determines that a patient is receiving take steps to make sure the treatment is legitimate before dispensing the prescription. Often, a patient who is seeing multiple prescribers is doing so just to obtain the drugs. That is defined in law as deception (doctor shopping) and that is a felony in Ohio. On the other hand, a patient who is being treated at a major cancer center clinic may really see multiple prescribers due to the clinical rotations of the hospital’s house staff physicians. In other words, do not automatically assume that a patient is doctor shopping until you do some checking.
One valuable tool in verifying the legitimacy of a patient (particularly a new patient) who presents a prescription for a controlled substance is to obtain an Ohio Automated Rx Reporting System (OARRS) report on that patient. The OARRS report will give you information (names, addresses, etc) on the prescribers and pharmacies used by that patient. If you find that the patient is receiving controlled substances from one prescriber (or one clinic) only, then your comfort level with the prescription should be better than it would be if you found the patient had visited 10 prescribers and eight emergency rooms in the last six months.
Patient profiles and OARRS reports are only part of the equation, however. In addition, the pharmacists need to know the prescribers and the patients. If the patient lives a long distance away from your pharmacy, it would be prudent to question why the prescription is being presented to you. While most of us think that our pharmacy is the best one around, it helps to be practical every now and then. Why would the patient need to drive from Portsmouth to Marion (or Columbus, or Zanesville, or Dayton) to get a prescription filled? Is your pharmacy really that outstanding? Furthermore, if the prescriber’s office is also located a long distance from your pharmacy as well as the patient, the question to ask is why does the patient need to drive here to fill the prescription.
Often pharmacists are the first to detect a physician who begins to stray from patient care into drug trafficking. We often get complaints from pharmacists when physicians begin to prescribe unusual quantities and unusual combinations of drugs. Pharmacists are often the first in the community (other than the drug abusers, of course) to realize that something is wrong. Please continue to monitor this issue and let us know when someone begins to stray.
Some indicators that there may be a problem with a physician who treats “pain” include patients that all get the same drug(s) in the same quantities (pain is not like an infection where one dose fits all); when most of the patients receive prescriptions for the highest strengths available (most patients do well on hydrocodone/APAP 5/325); when the doctor’s parking lot is full of cars from out of state or from several counties away; when you find that the doctor only takes cash; when the patients always pay you cash for their prescriptions (or they pay cash for the second prescription after Medicaid or another insurer paid for the first); or when the patients appear in van loads rather than individually, etc.
Even though the workload in most pharmacies is high and difficult to deal with on a daily basis, pharmacists must use good judgment when filling prescriptions. Pharmacists have a duty to the patients and to society to ensure that the drug therapy is appropriate and reasonable. Blindly filling a prescription without proper thought because you are too busy to spend the time to think before you act is a disservice to the patient, society, and the profession. Pharmacists have always been and still are the gatekeepers in this process. Legitimate patients should have their prescriptions filled in a timely and accurate method without being subjected to harassment or delay. Patients who are trying to obtain drugs to support a habit or to sell should not have their prescriptions filled. Determining which category an individual patient fits into is difficult at best, but both the prescriber and the pharmacist have an equal responsibility to make that call.
