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DRUG Diversion and Pharmacy

DRUG Diversion and Pharmacy. Dr. Phil Hopkins, Jr., RPh March 16, 2012. Objectives. At the conclusion of this presentation the HCP will understand: What constitutes pharmaceutical drug diversion. The names and types of the most commonly diverted and abused prescription drugs.

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DRUG Diversion and Pharmacy

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  1. DRUG Diversion and Pharmacy Dr. Phil Hopkins, Jr., RPh March 16, 2012

  2. Objectives At the conclusion of this presentation the HCP will understand: What constitutes pharmaceutical drug diversion. The names and types of the most commonly diverted and abused prescription drugs. The methods through which drug diversion is carried out in the pharmacy, including both internal and external, direct and indirect factors. The signs and symptoms of drug diversion Attempts towards Regulation and control of drug diversion in the pharmacy

  3. What is Drug Diversion? “Drug diversion is the illegal distribution, abuse, or unintended use of prescription drugs.” http://www.ticic.state.tn.us/what%20is%20drug%20diversion.htm

  4. What Kinds of Drugs Are Diverted?

  5. What Kinds of Drugs Are Diverted? • Opioids and opioid affecting • Lortab, Vicodin, Norco (hydrocodones) • Roxicodone, Oxycontin (oxycodones) • Morphine • Ultram, Ryzolt, Rybix ODT (tramadol) • Benzodiazepines • Ativan (lorazepam) • Klonapin (clonazepam) • Valium (diazepam) • Xanax (alprazolam)

  6. What Kinds of Drugs Are Diverted? • Hypnotics • Ambien (zolpidem) • Lunesta (eszopiclone) • Sonota (zaleplon) • Stimulants/Weight Loss • Adderall, Vyvanse (dextroamphetamines) • Ritalin, Concerta, Focalin (methylphenidates) • Adipex-P (phentermine)

  7. What Kinds of Drugs Are Diverted? • Muscle Relaxants • Soma (carisoprodol) • Flexeril (cyclobenzaprine) • PDEI’s • Cialis (tadalafil) • Levitra (vardenafil) • Viagra (sildenafil) • Rehab Drugs • Suboxone, Subutex, Butrans (buprenorphine)

  8. Processes of Pharmacy Based Drug Diversion Multiple access points for medication misuse

  9. Direct Personal Use • Accomplished via theft in the pharmacy • Can also be accomplished via street purchase of drugs that started in the pharmacy • Occurs among both technicians and pharmacists

  10. Direct Personal Use (examples)

  11. Direct Personal Use • 12 to 15% of all HP’s misuse drugs at some point in their career • Journal of American Pharmacists Association (2004) • 58.7% of pharmacists reported using a non-prescribed drug at least once in their lifetime • Journal of Physician Assistant Education (2011) • 10.4% of students surveyed had either used a stimulant or was using prescription stimulants illegally. • Most common reason for stimulant use was to focus and concentrate during studying

  12. Direct Pharmacy Theft • Drugs dispersed to the broader market through theft • Pharmacist or technicians steal medication not just for personal use, but to sell on the broader market. • This creates access opportunities for drug seekers

  13. Direct Pharmacy Theft /

  14. Indirect Pharmacy Theft • Accomplished through pharmacy robbery by non-pharmacy people • Drugs available on the broader street market • Thefts on the rise

  15. Indirect Pharmacy Theft • Knoxville: robberies jumped from 26 in 2009 to 44 in 2010 • In January 2011 Knoxville has already seen 5 robberies • 10 robberies in four months in Chattanooga Walgreen’s

  16. Doctor Shopping • The process of seeing multiple doctors for the same medications • Is a felony in Tennessee as of 2007 • Feeds both personal drug addiction and sale/distribution to the broader street market • Major challenge for pharmacists in spite of computers

  17. Doctor Shopping and TennCare

  18. Prescription Forgery • Alteration of existing prescription • Pad theft • Phony Phone-ins

  19. Willing Prescribers • All aboard “the Oxycontin Express” • Are not unknowingly taken advantage of • Work for pain clinic owners (no longer in TN) • Churn out narcotics prescriptions and rubber stamp therapy • Contributes to abuse • Amounts to thousands of street drug pills

  20. Willing Prescribers • Advertise hundreds of miles away • Operate out of strip mall store fronts

  21. Willing Prescribers

  22. Signs & Symptoms of Drug Diversion • One size fits all prescribing • Inappropriate drug choice/dose • Medical background of prescriber • How clinic operates • New patient to pharmacy? • Cash paying? • Out of town? • Young and very mobile • Not aware of drug’s purpose (Sudafed)

  23. Suboxone: The No-Cure Cure? • Drug originally approved for opioid withdrawal • Naloxone component supposed to prevent abuse • Tenncare: • October 2008 = approx. 1,900 claims • December 2011 = approx. 4,100 claims • No doses above 16mg will be approved • Street value currently $8 to $30

  24. Regulation and Control Methods of minimizing drug diversion

  25. Tamper proof prescriptions • Why make a prescription tamper proof? • Tamper proof requirements • All Medicaid starting April 2008 • In Tennessee applies to all prescriptions written in TN • Slightly effective • Cannot erase and change • Cannot forge easily • Can add to it • Pads can be stolen

  26. Tamper Proof Drugs • Prevents non-oral misuse • Some drugs have been tamper proofed • Vyvanse • Oxycontin • Opana ER • Embeda

  27. On Site Prevention • Sept 2010 to March 2011: 17 Walgreen’s pharmacies robbed in Knoxville • March 2011 to July 2011: 2 Walgreen’s pharmacies robbed and 1 failed attempt in Knoxville

  28. Tighter Prescribing Laws • Pain management laws enacted in Florida Texas and Tennessee among others • Tennessee’s law • Owner must be operator • Cash only accepted for insurance co-pays • Must apply for Pain Clinic certification • Board inspections include patient record keeping and documentation

  29. Monitoring Databases • Controlled Substance Monitoring Database • All prescribers and pharmacies/pharmacists must have access • Allows physicians to see doctor shopping within the state • Currently is not real-time or multi-state • NPLEx for pseudoephedrine • Is a real-time database • Checks across all states in which NPLEx is used • Alerts law enforcement to repeated failed attempts • Blocks over limit and convicted from purchasing PSE

  30. The Tough Road Ahead

  31. Suggested Reading • Directly Related: • The Cult of Pharmacology by Richard DeGrandpre, Duke Medical Press, 2006. • Other • How Doctors Think by Jerome Groopman • Complications: A Surgeon’s Notes on an Imperfect Science by AtulGawande • Better: A Surgeon’s Notes on Performance by AtulGawande • The Checklist Manifesto by AtulGawande

  32. Sources Signal teacher indicted: http://www.timesfreepress.com/news/2009/jul/04/signal-teacher-indicted-on-theft-drug-charges/ 46 Health Care Professionals: http://www2.tricities.com/news/2009/apr/27/46_health_care_professionals_linked_to_substance_a-ar-247170 Kenna, G and M Wood. Prevalence of substance use by pharmacists and other health professionals. J Am Pharm Assoc (2003). 2004 Nov-Dec;44(6):684-93. PMID: 15637851 Lifetime misuse percentages: http://www.allbusiness.com/crime-law-enforcement-corrections/law-police-forces/16723470-1.html Pharmacy robbery pic: http://www.wkrn.com/story/15031856/police-arrest-suspect-in-clarksville-pharmacy-robbery Herman L. The use of prescription stimulants to enhance academic performance among college students in health care programs. J Physician Assist Educ. 2011;22(4):15-22. PMID: 22308929 Street Drug prices: http://www.tndrugdiversion.org/Average%20Street%20Prices.htm Knoxville robbery stats: http://www.stopoxy.com/clear-sign-epidemic-pharmacy-robberies

  33. Sources DS a Felony in TN: http://www.fiercehealthcare.com/story/tn-makes-doctor-shopping-felony/2007-08-07 Suboxone clinics: www.suboxone-directory.com/tennessee Tuten, Michelle. Abstinence-contingent recovery housing and reinforcement-based treatment following opioid detoxification. Addiction. 2011 Dec 7. doi: 10.1111/j.1360-0443.2011.03750. PMID:22151478 Pain clinic store front: http://talkmarioncounty247.squarespace.com/a-photo-a-day/2010/9/9/day-249-left-behind-lebanon-medical-solutions.html Pain clinic ad: http://www.marioncountyline.com/2010/08/lebanon-pain-clinic-ad.html Pain Clinic Raid: http://www.daily-tribune.com/view/full_story/13956108/article-Authorities-bust--pill-mill--at-Cartersville-pain-clinic Pain Clinic on Topix: http://www.topix.com/forum/city/cartersville-ga/T0GLPL7M5QGRC1HSB/p2 AMG Details: http://www.daily-tribune.com/view/full_story/14518560/article-Feds-arrest-5-in--pill-mill--operation Times Free Press: Chattanooga Time Safes: http://www.timesfreepress.com/news/2011/sep/13/b1-walgreens-to-use-time-delayed-locks-on/ Post Time Safe Knox stats: http://www.wate.com/story/15050513/walgreens-says-time-delay-safe-preventing-knoxville-pill-robberies TN Pain Clinic Law: http://www.capitol.tn.gov/Bills/107/Bill/HB1040.pdf

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