Transcript Idaho Law Updates - Idaho Society of Health

Pharmacist Red
Flags and the Idaho
PMP
Marcus C. Hurst, PharmD
Retail Pharmacist
Albertson’s/Save-On
March 5th, 2016
Disclosures
• No disclosures or conflicts of interest
Learning Objectives
• Understand the scope of the drug abuse epidemic
• Examine the pharmacist’s role in the prevention of controlled
substance abuse and misuse and the laws pertaining to
pharmacists
• Recognize red flags for pharmacists
• Employ the use of the Idaho PMP into our practice of
pharmacy
The Population and Rx Drugs
• 52 Million people in the US, over the age of 12, have used
prescription drugs non-medically in their lifetime.1
• 6.1 Million people have used them non-medically in the past
month (January 2013).2
• The United states makes up 5 % of the world’s population,
but we use 75% of the world’s prescription drugs.3
1Substance Abuse
and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use and Health: Summary of
National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD: Substance Abuse and Mental Health Services
Administration, 2012.
2Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (January 8, 2013). The NSDUH
Report: State Estimates of Nonmedical Use of Prescription Pain Relievers. Rockville, MD.
3UNODC, World Drug Report 2011 (United Nations Publication, Sales No. E.11.XI.10).
CDC’s Top 10 List (2010)
Ten things you should know about prescription
drug abuse.
1. Drug overdoses kill more Americans than auto
crashes
• 38K deaths in 2010, with 16.5K of those due to pain killers
2. Enough pain killers for every American adult q4h x
30 days
3. Painkiller Rx deaths quadrupled between 1999 and
2010
4. One in Twenty Americans used pain killers for nonmedical reasons in 2010
5. The public has a responsibility to prevent it
CDC’s Top 10 List (2010)
Ten things you should know about prescription
drug abuse.
6. We need effective public health interventions
7. States need to implement and improve PMP
8. States can enforce policies to reduce diversion,
abuse and overdose.
9. States/communities need to enhance access to
treatment
10. Health care providers should use evidence-based
clinical guidelines and practices to promote safe and
effective use of prescription painkillers
Website: http://www.pbs.org/newshour/rundown/prescription-drug-abuse-top-10-things-cdc-says-you-should-know/
Assessment Question #1
• The United States makes up ____% of the world’s population,
but consumes ____% of the world’s prescription drugs?
A.
B.
C.
D.
5 and 75
10 and 90
15 and 50
20 and 40
The Pharmacist’s Role
The NABP encourages collaboration and defines a
pharmacist role as complex and sometimes conflicting
• Regardless of practice setting, the basis and essence of
pharmacist care includes:
• Communication
• Education
• Information exchange between patients/caregivers/prescribers
• Central point of pharmacist care is the management of
medications
• Positive patient outcomes
• Patient-centered medication therapy management
National Association of Boards of Pharmacy (NABP), Stakeholders’ Challenges and Red Flag Warning Signs Related to Prescribing and Dispensing
Controlled Substances, March 12,2015
The Pharmacist’s Tools
• The CDC considers prescription drug abuse an “Epidemic”
in the United States.
• The solution:
• Safe prescribing practices
• Safe and sensible
• State policies
• Regulating pain clinics and improving access to naloxone
• Prescription Drug Monitoring Programs
• https://idaho.pmpaware.net/
Website: http://www.cdc.gov/drugoverdose/epidemic/
This Includes You
Safe Prescribing Practices = Corresponding Responsibility
• Title 21 Code of Federal regulations
• Part 1306 – Prescriptions
• 1306.04 Purpose of issue of prescription
• a) A prescription for a controlled substance to be effective must
be issued for a legitimate medical purpose by an individual
practitioner acting in the usual course of his professional practice.
The responsibility for the proper prescribing and dispensing of
controlled substances is upon the prescribing practitioner, but a
corresponding responsibility rests with the pharmacist who fills
the prescription…
• and the person knowingly filling such a purported prescription, as
well as the person issuing it, shall be subject to the penalties
provided for violations of the provisions of law relating to
controlled substances.
You are a Naloxone Prescriber
Pharmacists can prescribe and dispense Naloxone
• Idaho Code 54-1733B Opioid Antagonists
• (1)Notwithstanding any other provision of law, any prescriber or
pharmacist acting in good faith and exercising reasonable care
may prescribe an opioid antagonist to:
•
•
•
•
Any person at risk of opiate-related overdose
A person in a position to assist person at risk of overdose
A person who may encounter another person experiencing overdose
A person with valid reason to be in possession of opioid antagonist
• (2) Administer, then contact emergency medical services ASAP
• (3) Any person who prescribes or administers an opioid
antagonist pursuant to subsection (1) or (2) of this section shall
not be liable in a civil or administrative action or subject to
criminal prosecution for such acts.
Idaho Prescription Monitoring
Prescription Drug Monitoring Programs
• Idaho Code 37-2726 Filing Prescriptions – Database
• (1) All controlled substances dispensed for humans shall be filed
with the board electronically in a format established by the board
or by other method as required by board rule….
• (2) The board shall create, operate and maintain a controlled
substances prescriptions database… The database information
must be made available only to the following:
• Prescribers, Board, Peace officers, H&W, practitioners, individuals
own record, by judges orders, some attorneys
• (e) A pharmacist, licensed in Idaho or another state, having
authority to dispense controlled substances to the extent the
information relates specifically to a current patient to whom that
pharmacist is dispensing or considering dispensing any controlled
substance, or providing pharmaceutical care as defined in the Idaho
pharmacy act;
Idaho Prescription Monitoring
Prescription Drug Monitoring Programs (Cont…)
• (3) The board shall require prescribers, except veterinarians, to
annually register with the board to obtain online access to the
controlled substances prescriptions database.
• (4) The board must maintain records on the information
disclosed from the database, including:
• Person Requesting, what was provided, date/time it was accessed
• (5),(6),(7),(8) …misdemeanor, punishable by imprisonment in a
county jail not to exceed six (6) months or by a fine not to exceed
two thousand dollars ($2,000), or both.
•
•
•
•
•
DON’T get a login unless you meet the criteria
DON’T share your login
DON’T share information from the database
DON’T access information that you don’t need
DO keep your login information safe
Assessment Question #2
• Which of the following health care providers are NOT required
to register for the Idaho prescription monitoring program?
A.
B.
C.
D.
E.
Physician’s Assistant
Pharmacist
Nurse Practitioner
Dentist
MD or DO
Pharmacist Red Flags
Most Common, Easily recognized
• Early refill requests
• What is the cut off? 80%? 90%?
• 30 day Rx:
Cutoff
Used
Days Early Refills/Year
Tabs/Year
80%
24
6
15
450
90%
27
3
14
420
95%
28
2
13
390
• Same drug, different prescriber
• Dr. Shopping
• Multiple pharmacies
• How would you see this outside your own system
Pharmacist Red Flags
Most Common, Easily Recognized
• Cash paying patients
• Under the new Affordable Care Act, insurance is required
• Idaho Medicaid increased income levels in 2013
• Some situations where day supply limited by insurances
• Suspicious behavior
•
•
•
•
Over talkative, distracting pharmacist
Nervous
Agitated
Defensive
Pharmacist Red Flags
Less Common, Take Time To Recognize
• Forgery
• Alterations
• Spilled Coffee
• Eraser marks
• Smudges
• Different Ink/Handwriting
• Nurse Writes Rx, Provider Signs
•
•
•
•
Misspellings
Missing information
No abbreviations
Non-standard instructions
Pharmacist Red Flags
Less Common, Take Time To Recognize
• Geographical Flags
• Out of State
• Out of Region
• Out of Town
• Large Quantities
• Drug cocktails
• Opioid + Benzodiazepine + Muscle Relaxer
• Antagonistic Drugs
• Depressants and Stimulants
• Out of Specialty
• Dentist writing for ADHD
Pharmacist Red Flags
Less Common, Take Time To Recognize
• Unlikely coincidences
• Multiple patients with the same address, different last name
• Multiple patients together, same provider, same meds
• Going out of the country after recent pickup
• Providers from other parts of the country?
• Virtual visits from providers
• Most won’t prescribe controls or muscle relaxers
Assessment Question #3
• Which of the following does NOT contain a pharmacist red
flag?
A. Mr. Jones is a new customer to the pharmacy and wants to
know how much his prescriptions will cost. He does not have
insurance, but will use his credit card to pay for them.
B. Dr. Phil D. Cavity, D.D.S. is calling in his daughter’s birth control
medication and wants to be sure that she receives a 90 day
supply before she leaves for college.
C. Antonio Aikenhed has a prescription for a controlled substance,
but the hardcopy appears to have coffee spilled on it. The ink is
smudged but is still legible.
D. Mrs. Shields, a regular patient, is in the pharmacy to fill a
controlled substance prescription for the same drug that she
received 30 days ago, but this month the patient went to see a
different prescriber.
Pharmacist Tools
The pharmacist is the last line of defense
• What are your resources?
• Pharmacist intuition?
• Patients are smarter, sneakier, prepared
• Your own system?
• Patient history
• What if the patient fills with multiple pharmacies
• The Idaho BOP (http://bop.Idaho.gov)
• Laws/Rules/Etc.
• Home Study CPE Program - "Changes Pharmacists May Make to
Schedule II Prescription Drug Orders”
• Idaho Red Flags Video
THE Pharmacist Tool
• Idaho Prescription Monitoring Program
•
•
•
•
Every single CS Rx has potential for abuse
Every single patient has a potential for abuse
Every single pharmacist has access to the PMP
Every single CS prescription can be checked
• Faster than searching your own system
• Shows CS Rxs at ALL Idaho/Partner Pharmacies
• 100% of prescribers are signed up (required)
• Board working on legislation to require use on C2 prescribing
• How many pharmacists are signed up?
• How many pharmacists are using it?
Idaho PMP
An Invaluable Tool in Fulfilling Your Corresponding Responsibility
• Access to multiple states
• Idaho and neighbors: Utah, Nevada, Colorado
• Arizona, New Mexico, North Dakota
• Ohio, Illinois, Indiana, Kansas, Michigan, Minnesota, Mississippi
• Easy to use
• Required for search: First name, Last name, DOB
• New Feature
• Partial First name
• Partial Last name
• Easy to sign up
• Tutorial on bop.idaho.gov
Accessing the Idaho PMP
Accessing the Idaho PMP
Accessing the Idaho PMP