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'Opiate Refugees' Caught Between Pharmacies, Suppliers And The Law

Flickr Photo/Greg McMullin (CC-BY-NC-ND)

This week the state Department of Health reported that prescription drug overdose deaths are down 27 percent since 2008. But curbing fraud and abuse of powerful opiates has come at a price for some legitimate patients who say they’re suffering unnecessary pain due to delays at pharmacies. 

“This situation has literally brought customers to tears in our store,” said Doug Hoey, CEO of the National Community Pharmacists Association, reading from comments submitted to a survey by the association’s members.

'We're Cutting It Off'

Hoey said they created the survey because of increased concerns among pharmacists who are running into problems when they order painkillers and other controlled substances from suppliers. Sometimes, he said, the drugs are just not there, and the explanation is vague.

[asset-pullquotes[{"quote": "This situation has literally brought customers to tears in our store.", "style": "inset"}]]“When we talk to the suppliers, they say the Drug Enforcement Agency has come in and said that ‘we’re supplying too many,' or 'they’re watching us.’ But they don’t give us any guidelines on what 'watching us' means,” Hoey said.

According to Hoey, the suppliers tell the pharmacists that they are reviewing what they are shipping and erring on the side of caution: “'If we see anything that looks suspicious to us, we’re cutting it off.’”

The scenario is so prevalent that patients in this situation have been dubbed “opiate refugees.” Patients are forced to go from pharmacy to pharmacy trying to fill legitimate prescriptions.

Not Just A Supply Chain Issue

Some large pharmacy chains have instituted polices requiring pharmacists to ask a host of new questions before filling prescriptions. They’re scrutinizing how far away a patient lives from the pharmacy and, in some cases, calling doctors to inquire about treatment plans and the number of times they’ve seen the patient. If every question can’t be answered satisfactorily, the patient may leave empty-handed.

Even if the pharmacist believes the prescription is legitimate they may feel pressure not to fill it because they could be fired. It’s an ethical dilemma, and it could be a legal one.

[asset-pullquotes[{"quote": "It's all been dumped in our laps as wholesalers to make what I would consider to be law enforcement decisions.", "style": "inset"}]]The policy concerns state health officials like Chris Humberson, executive director of Washington State Pharmacy Quality Assurance Commission. “Pharmacists that are licensed and companies that operate pharmacies do have a legal obligation to provide all patients in Washington state access to medication,” Humberson said.

Doctors, patients and pharmacists are starting to complain to the Pharmacy Quality Assurance Commission and the state Department of Health. The state is already investigating at least four cases where a pharmacy’s policy may have overstepped state law.

Most of the chain pharmacies KUOW contacted would not comment for this story. They also wouldn’t provide a copy of their corporate policy for dispensing.

However, in a written response Walgreens stated: “Our good faith dispensing policy is intended to be used consistently by our pharmacists for each individual prescription to determine whether the doctor’s office needs to be contacted.”

Humberson himself used to work behind the counter. If he had a concern about a prescription, he would just call the doctor, but he said he didn’t have to write down a diagnosis code or check when the doctor had last seen the patient.

The strict policies are a response to guidance from the Drug Enforcement Agency that some say is ambiguous. Pharmacies and suppliers are trying to comply to avoid fines or having their licenses pulled.  

When asked about the situation, the DEA's Barbara Carreno said regulations have not changed.  She added that any additional steps being taken by drug suppliers or pharmacies are not being imposed by the Drug Enforcement Agency.

John Gray, president and CEO of Healthcare Distribution Management Association, said suppliers used to have a more cooperative and collaborative relationship with the Drug Enforcement Agency. But things have changed, he said. “It’s all been dumped in our laps as wholesalers to make what I would consider to be law enforcement decisions as to whether or not a particular customer or account is or is not over what the DEA, in their own mind, thinks is a viable limit for Schedule II drugs they ought to be dispensing,” Gray said.

[asset-pullquotes[{"quote": "We have to find a way to curb the abuse and still find a relief from pain for those truly suffering.", "style": "inset"}]]'Show Your Rationale'

Pharmacists want to comply as well. They’re just not always sure how.

At Bob Johnson’s Pharmacy in Ballard, owner Mike Donahue is well aware of the street value of his supply, and all the problems that come with it.  

He’s been robbed for his painkillers in the past. He’s always on the lookout for red flags. Sometimes his customers and prescribers are uncomfortable with the questions he has to ask. “Things change and practice changes. If you’re going to prescribe narcotics in large quantities, then you need to be prepared when you’re writing that prescription to show your rationale because it’s something that’s going to be demanded somewhere along the road,” Donahue said.

The trick is for doctors to document that they’ve screened out a drug seeker while not alienating or turning away legitimate patients.

A pharmacist’s comment in Hoey’s survey seems to convey a sentiment that many in the industry are feeling: “We have to find a way to curb the abuse and still find a relief from pain for those truly suffering.”

That can only happen, Hoey said, with more transparency and collaboration.