A Behind-the-Counter Look at the Opioid Crisis

A Pharmacist's Perspective

Daniel S. Orlovich, MD, PharmD

Disclosures

November 21, 2017

There is a long line. With gray sandpaper-like stubble and an ill-fitting maroon T-shirt, I see him approach the pharmacy counter. His hand moves toward his back hip. And here comes the piece of paper for a pain medication. As a pharmacist, I've filled numerous prescriptions over 15 years, many of them for opioids. But this time something is different—his motion is fluid. My thoughts speed up. How many times has he done this before? My eyes squint as I follow his hand. His lips move, but I don't hear anything. Then I realize what is happening. He flashes his Drug Enforcement Administration (DEA) badge. I let out a sigh of relief while my muscles relax, and I let him in behind the counter. He is building a case against a person abusing prescription opioids; it will not be the last time I see him or someone from his unit.

I interpret such encounters as a clear message by the DEA. From 2006 to 2016, they have stepped up the fight against the opioid epidemic in the United States by increasing the number of special agents in the Tactical Diversion Squad Program by 385%.[1] And who could blame them?

  • In 2014, more than 60% of drug overdoses in the United States involved an opioid.[2]

  • Americans, while making up only 4.6% of the world's population, have been consuming 80% of the global supply of opioids.[3]

  • Over 3500 people started misusing opioid medications for the first time today.[4]

  • The majority of prescription opioids that are being misused are coming not from people buying them off the street but from legally written prescriptions.[5]

As a pharmacist, my verification is a lesser-known link between a legal prescription and a national epidemic.

It Is Already on Your Corner

The next person in line looks like any other person who works in the Financial District. He hands over his identification. I look at his address.

This is not rural West Virginia; this is San Francisco, California. This man lives in a city where the median home costs $1.2 million, more than half the population has graduated from college, and unemployment is a touch above half the national average.[6]

California is a state that the National Safety Council ranked high in terms of being able to effectively and comprehensively fight the opioid epidemic; only four states had more measures in place. Over half the nation earned a "failing" grade.[4] I've worked in some of those ''failing'' states too and even away from the city and in the suburbs.

It's typical to see a pharmacy on the street corner, maybe even two to a corner because they are so profitable. Pharmacy Times estimates that the two largest pharmacy chains, CVS Health and Walgreens, combined handled nearly $100 billion of prescription sales in 2014.[7] The most likely way a person at the highest risk for an overdose gets opioids is not through nefarious or illegal means but rather through his or her own prescription.[8] That means it is coming from a pharmacy.

It Is Completely Legal

The next person steps up to the counter. The technician turns to get my attention. I examine the piece of paper with the drug name written on it.

Out of view, I look closer at the prescription. I look at who wrote the prescription. I'm sure Dr Smith has good intentions and just wishes to treat some pain. After all, she is a primary care provider, and data show that primary care providers account for half of opioid pain relievers dispensed.[9]

I bring up the patient's profile. Sometimes I see obvious signs of abuse. One tip-off is a potentially dangerous mixture of medications prescribed by two or more prescribers or bought at multiple pharmacies. According to research by Express Scripts,[10] a mail-order pharmacy that ranked third in prescription revenue in 2015,[7] about 60% of patients taking chronic opioids were prescribed potentially dangerous combinations. Most were prescribed the drugs by more than one prescriber, and almost 40% used more than one pharmacy.[10]

I log into a Prescription Drug Monitoring Program (PDMP) to investigate further. Not too many years ago, a person could walk into every pharmacy on the block, pay cash for their controlled substances prescriptions, and walk out. Now, with this PDMP database, I can find where the patient picked up the last prescription, for how many tablets, which physicians wrote for them, and when they last picked it up.[11] It isn't perfect, but it helps. I hit enter and see the results.

I return to the counter, smile, and tell the patient to take a seat and that it will be ready in 15 minutes.

"In 2012, about 259 million prescriptions for opioids were written, which was more than enough to give every American adult their own bottle."

I reach for the bottle—it is right in front of me on the "fast rack" or "speed shelf," as we call it, because it is a medication used so often that it is within arm's reach. I grabbed it just 5 minutes ago for another patient. Most bottles have 100 pills in them. This one has 500. And there are four additional bottles in the back. I leave it close to the filling station because chances are I will have to grab it again soon.

In 2012, about 259 million prescriptions for opioids were written, which was more than enough to give every American adult their own bottle.[12] Former US Surgeon General Dr Vivek Murthy noted publicly that there is enough for every adult in America to have a bottle of pills "and then some."[13] The Centers for Disease Control and Prevention noted that the sales of prescription opioids in the United States quadrupled from 1999 to 2010.[14]

My voice sounds on the overhead system telling the person the medication is ready.

It Affects Us All

Next in line is an elderly lady who carefully maneuvers toward the counter. I notice her cane. Which hip did she break?

With swollen fingers, she takes out a crisp blue prescription and slides it across to me. She leans forward at the counter as if she were about to reveal a secret. And at that moment, it sinks in.

"Am I gonna get addicted?"

I realize that the opioid crisis affects everyone—even grandmas. Even having lived through two world wars and two great depressions, she was deeply concerned about getting hooked on 20 pain pills after an orthopedic procedure in which the strongest bone in her body cracked in half and is now supported with a rigid metal rod.

Statistically, her age, sex, and ethnicity are in line with those more likely to use prescription opioids. Non-Hispanic whites are more likely to use than Hispanics, but no difference exists between non-Hispanic whites and non-Hispanic blacks. Adults aged 40 years and older are more likely to use than adults aged 20-39 years, and women are more likely to use than men.[15,16] Using, however, is different from abusing.

The opioid crisis affects us all.

It Is Complicated

Let's start with the party that a 2017 survey of US adults found to be most responsible for the nation's opioid crisis—the users.[17] To those with a legitimate medical need, from the elderly with a cane to the mothers who just gave birth, pain is a barrier to functioning in the activities of daily living. According to the Institute of Medicine[18] and a study from the Journal of Pain,[19] more than 30% of Americans have some form of acute or chronic pain. To those previously healthy, from construction workers who had some lower back tightness to the parent undergoing a routine dental procedure who is hiding an amber bottle in the house from her teenagers, opioid use creates an opportunity for destruction. Once, it was meant to control their pain. Now it controls them. How quickly do people get hooked? Big data in a recent study suggested a sobering fact: possibly by the fifth day.[20]

"How quickly do people get hooked? Big data in a recent study suggested a sobering fact: possibly by the fifth day."

The next group that survey participants accused of being responsible for the epidemic is the physicians. To the ethical providers, the act of prescribing opioids blurs the line between alleviating pain and unintentionally starting an addiction. Studies suggest that as many as 1 in 4 patients who receive a prescription for an opioid are already struggling with addiction,[21] resulting in 1000 people treated in the emergency department daily for misusing prescription opioids.[22]

The next group charged with being responsible is the pharmaceutical companies. Earlier this year, we saw an unprecedented recommendation from the US Food and Drug Administration (FDA) to remove one long-acting opioid (Opana® ER) from the market.[23] In a move that may affect other manufacturers as well, the DEA reduced the amount of opioid medications that may be manufactured in 2017 by 25% or more.[24] For some pharmaceutical companies who have already profited off of opioids, there are lawsuits aimed at investigating their role in fueling the opioid crisis. Lawsuits in Illinois, California, Mississippi, New York, Ohio, and Kentucky have been filed.[25,26]

The next person in line approaches. Is it you?

Pain is real. So is watching this opioid crisis play out from behind the counter.

Follow Daniel Orlovich, MD, PharmD, on Twitter: @DrOrlovich

Follow Medscape Pharmacists on Twitter: @MedscapePharm

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