Safety and Controlled Substances

• Prescription and illegal drug abuse and growing national problems that need to be addressed by the pharmacy field

• The abuse of prescription pain medication is the fastest-growing drug problem in the United States

• Drug overdose is the leading cause of accidental death in the United States, with opioids being the most common drug. The CDC currently estimates more than 1000 emergency department visits daily related to the misuse of opioids and about 91 opioid overdose deaths every day

• According to the CDC, an estimated 107,622 drug overdose deaths occurred in the U.S. in 2021, an increase of nearly 15% from the 93.655 deaths estimated in 2020. Of the 2021 deaths, almost 81,000 were attributable to opioids, primarily fentanyl. The CDC notes that deaths from “psychostimulants,” such as Ecstasy and cocaine, also increased in 2021 compared to 2020.

Physical and Psychological Dangers of Dependence

• Drug dependence is a complex and difficult mental health and biological problem that affects individuals, families, and communities, contributing to crime and violence

• Prescription drug and controlled substance dependence often begin with drug tolerance and progressively escalate to dependence, both psychological and physical, and then to completely controlled addiction

  • Drug tolerance: When the body adapts to a drug so that higher doses are needed to produce the same pharmacological effect. Long-term drug tolerance can lead to psychological and physical dependence, and addiction

  • Psychological dependence: When the patient takes a drug on a regular basis because it produces a sense of well-being that the patient does not want to consider being without. If the patient stops taking the drug, they experience anxiety or withdrawal symptoms due to the psychological security that the drug offered

  • Physical dependence: Taking a drug continuously so that when the medication is stopped, physical withdrawal symptoms occur, such as restlessness, anxiety, insomnia, diarrhea, vomiting and goosebumps. Commonly occur with high dose of Schedule II drugs.

  • Addiction: A chronic disease marked by compulsive and uncontrollable use of a drug substance. Characterized by a powerful, compulsive urge to use a drug or substance when it is to required medically. Builds on a spectrum of increasing severity the longer it goes unchecked.

Prescription Strategies to Fight Abuse

Recommendations to avoid or discontinue the use of opioid medications:

• Start at a low dose, perhaps half the usual, and go slowly with dosage increases

• Avoid mixing with alcohol or any other medications

• Monitor medications and follow up with the doctor often

• Be realistic and don’t expect a medication to take away all aches and pains

• Try to find nonpharmaceutical ways to reduce pain, such as yoga, rehabilitation therapies, meditation, and others

• Keep prescription in a locked drawer or cabinet

Prescription Techniques for Abuse Prevention

1. Be on the lookout for drug seekers

   • Patients who constantly request “early refills”

   • Patients who receive prescriptions for the same or similar controlled drugs from several physicians “doctor shoppers”

   • Patients who often pay with cash to minimize insurance tracking

2. They are most likely psychologically or physically dependent or addicted to the medication, or might be selling the drugs

   • May try to be extra kind and flatter the pharmacy staff to gain your trust

   • If the prescriptions come from the ER they might often only request the pain medication be filled

3. Be aware that another person might be attempting to call in a refill or pick up a prescription for a controlled substance. When in doubt always reach out to the patient.

Watch for Prescription Forgeries

1. DEA Number Check

2. Out-of-State prescriptions and patients, especially at night and on the weekends

If a forgery or drug seeking behavior is suspected, retain the prescription, try to detain the individual, and notify the police. Suggest the patient come back in an hour. Always get a name and phone number.

The Right of Refusal

A pharmacist always have the right of refusal, declining with cause to fill any prescription, especially those for controlled substances

Red Flags: Trying to fill a narcotic prescription for severe pain written 3 months ago; changing day supply and offering to pay cash; numerous pain medications on profile; prescriber writing excessive amounts or writing outside of their scope of practice.

The DEA has launched a texting tip line in some areas to anonymously report suspicious prescription drug activity. Type TIP411 for the phone number, then type DEADRUGS or PILTIP. Text a description of the suspicion or send an image.

State and Federal Efforts for Prevention

Prescription Drug Monitoring Program (PDMP) is a program that gathers data for monitoring, tracking, and analyzing trends and sharing information on drug dispensing. This helps professionals to:

• Share information and work together to make informed decisions about dispensing controlled substances and reducing abuse

• Improve the quality of health care by limiting the use of medications to proper treatment of pain and terminal illness

• Reduce overprescribing and duplication in controlled substance prescriptions

Prescribers and Pharmacists Work to Prevent Opioid Abuse

• One of the problems we face is that there is no system to alert physicians of patients who nearly died of overdose and they often receive refills or new prescriptions for opioids

• Prescribers are encouraged to use e-prescriptions for controlled substances instead of written prescriptions

  • Use tamper-resistant paper and lock up blank prescriptions when not using them

  • It is illegal for a physician to write a prescription for a CSII drug for a family member and it is considered unethical to write a CS III or IV for themselves or a family member

Pharmaceutical Temptations for Abuse and Theft in the Pharmacy

• Health professionals (physicians, nurses, pharmacists) often fall victim to drug abuse and controlled substance diversion

• It is estimated that more than 10% of healthcare professionals have a drug or alcohol abuse problem

• Diversion and cause occur for multiple reasons: self medication to relieve stress or pain, improve work performance and alertness, or to sell and make money

• Most state boards of pharmacy have a Pharmacists Recovery Network (PRN) or similar organization to provide assistance and treatment for impaired colleagues without the risk of losing their license or registration

Preventing Pharmacy Robberies

• Retail pharmacies, due to the presence of money and especially drugs, are targets for robberies from criminals and addicts

• RxPatrol is a crime prevention and training program designed to collect, collate, analyze, and disseminate pharmacy theft information. They provide training videos and a security checklist to help make pharmacies safer.

  During a robbery, remember to REACT:

  R - Remain Calm, comply, and do not resist

  E - Eyewitness; remember all you can, such as age, height, weight, race, gender, body markings, and clothing

  A - Activate your panic alarm when safe

  C - Call Police; describe incident, robber, and their mode and direction of travel

  T - Take Charge; lock the door so the robber cannont return, protect the crime scene, keep customers calm, and have them remain in the store as witnesses when police arive