Pharmacists on the Front Lines


Written by Rosalind Fournier   Portraits by Beau Gustafson

brad-nelson-oneJ. Bradley Nelson, Pharm.D., experienced his first, up-close-and-personal moment of reckoning with our nation’s prescription-drug-abuse crisis almost a decade ago. As crime stories go, it’s relatively low on drama—no violence, no threats, no loud confrontation. A woman simply handed him a suspicious-looking prescription, and after taking a quick, discreet inventory of the situation, Nelson was forced to make a call that no pharmacist really wants to make.

“There’s a feeling you get that something is not right,” Nelson explains, describing the initial alarm bell that causes a pharmacist to use the other tools at his or her disposal, including calling the prescribing doctor’s office to verify a prescription’s validity. “On this particular prescription, it looked like it had been altered. The signature on the paper didn’t match the writing on it, and it was being brought in for a ‘friend.’ So whenever something like that comes up, the first thing you do is call the doctor, and the doctor says, ‘I’ve never heard of this person in my life.’”

Nelson, who now works for Proxsys Rx, a health-services company focused on managing and integrating outpatient pharmacies into the continuum of care for hospitals, and health systems, worked for a community pharmacy in Bessemer at the time. Local law enforcement had specifically requested that pharmacies contact them if they received forged prescriptions, and to follow his conscience and ethical duty—and also for the safety of the patient herself—he knew he had to make the call. But he still felt “absolutely horrible,” he remembers.

“I walked them through the steps I’d taken to positively identify that it was an illegitimate prescription, and they told me to stall and then go ahead and let her purchase it, because they were waiting outside for her.

“They walked me through the process of what they needed to be able to legitimately prosecute her to the fullest extent of the law at this point.”

An arrest like that makes for an easy day for trained law enforcement. For a pharmacist, trained to be a member of the continuum of healthcare professionwho work every day to meet patients’ healthcare needs…well, this is not what they signed up for.

A National Epidemic

According to the Centers for Disease Control, in 2015 more than six out of 10 drug-overdose deaths in the United States involved an opioid, and deaths from prescription opioids such as oxycodone, hydrocodone and methadone have more than quadrupled since 1999. And Insurance Journal, among other sources, reports that Alabama has the highest level of prescription opioid use in the country. Alabama physicians wrote 5.8 million prescriptions for opioids in 2015, enough for 1.2 prescriptions for every citizen in the state.

While many people who become addicted to opioid painkillers graduate to heroine—a cheaper way to feed a costly addiction—that still means an alarming number of people are relying not on the corner drug dealer in a shady neighborhood to get the drugs they crave, but pharmacists. It forces pharmacists into playing an unwanted role of prescription detective.

Last year, former Gov. Robert Bentley formed a comprehensive task force on opiate abuse to begin looking at ways to reduce the rising number of drug overdoses, including proposing new regulations. Nelson serves as part of a subprogram called the Data-Driven Prevention Initiative on Opioid and Heroine Abuse and Overdose.

The task force was formed not only in response to the alarming number of deaths but the many cracks being detected in the protection plans previously put in place. Michael Hogue, Pharm.D., PAPhA, FNAP—who serves as associate dean in the Center for Faith and Health and a professor of Pharmacy in the College of Health Sciences at Samford University—easily points to several. For one, there are state databases with information about a patient’s prescription history that are available to medical professionals, but no true national database, so a patient determined to circumvent the system can simply cross state lines and have prescriptions written by doctors or filled by pharmacists who are unaware of any duplications.

“And frankly not every state requires every physician or pharmacist to check that database before they prescribe,” Hogue explains. “In some states, the pharmacist has to check, but the doctor doesn’t. In some cases, neither the pharmacist nor the doctor is required to check the database; it’s just a reference. So that’s a problem.”

When it comes to forgery, he emphasizes that students who graduate from Samford’s McWhorter School of Pharmacy are well trained at recognizing prescriptions that have been forged or altered in any way, and the increased use of electronic prescriptions helps, as well. But there are still holes in the system. For instance, he wishes more doctors would take advantage of the opportunity at the time of prescribing to describe the nature of the patient’s medical situation. “The pharmacist has to make some degree of judgment about the legitimacy of the prescription they are presented with,” Hogue says. “It helps the pharmacist to understand what the diagnosis is. Unfortunately, in about 90 percent of the prescriptions that are being transmitted—at least that many—the physician is not transmitting the diagnosis of the patient to the pharmacist, so the pharmacist is not able to know. That puts the pharmacist in a very difficult position as it relates to protecting the public’s health, because if the pharmacist is not aware of what’s going on with the patient, how can the pharmacist as the medication expert best advise the patient as to whether or not the dose of the medicine is correct or the duration makes sense? When a doctor has written a prescription for 100 tablets of hydrocodone to a patient and there’s no diagnosis, as a pharmacist I’m going to say, ‘That’s a lot of hydrocodone tablets. What’s going on?’ And if the patient tells me, ‘I just had to have a mastectomy following breast-cancer surgery,’ I’m going to say, ‘Oh, that may make sense.’ Or if the patient says, ‘I just had a tooth pulled,’ that makes no sense whatsoever.”

Hogue also notes that while one of the most straightforward ways to catch bad prescriptions—those that are forged, tampered with or just written incorrectly—is contacting the prescriber, a lot of opioid prescriptions are presented late at night at 24/7 pharmacies, long after doctors’ regular office hours.

“So those are the dilemmas that you’re faced with. When you have a problem as big as the opioid thing, there are no easy answers.”

These are all issues being studied by the state task force, the Alabama Pharmacy Association, and many other groups. They have helped to make naloxone, a drug which reverses the effects of heroin and other opioids in case of overdose, available to first providers, pharmacists and even patients themselves who are addicted to opioids (or family members of addicts) in order to help prevent overdose deaths. They are working to close loopholes in the prescription database system.

And in many cases, Nelson says, pharmacists are simply learning to trust their instincts, because so much is at stake. “You have to have a really good level of discernment, particularly in the community setting,” he says. “You have to be able to discern people’s intentions, and sometimes your sixth sense starts screaming at you and telling you hey, there’s an issue here, and you need to recognize it. That instinct has served me well, and I know it’s served a lot of my colleagues well. I don’t know of anybody in my circle who has made a rash judgment to cause an innocent person to be accused of something.”

If something doesn’t look right, Nelson adds, one option is just to inform the patient he or she will have to wait until a prescription can be verified. “There are times where I’ve flat out told someone, ‘I’m going to keep this prescription until I verify it’s correct,’” he says. “You tell them up front that there’s something off about the prescription—it’s not filled out correctly, or whatever it is—so you’re calling the doctor to make sure that all the parameters of this prescription are met. And then you won’t see them again. And that’s kind of your realization, well, your hunch was right.

“Any time you do something like that and you get it off the street—particularly if it’s a prescription pad—it’s a good thing.”

Measuring Pain

Of course, plenty of opioid painkiller prescriptions are legitimate, and Hogue and Nelson believe pharmacists can continue to fulfill their role in filling those prescriptions safely while also playing a valuable role in prevention addiction to these powerful medications.

Still, Hogue admits there are obstacles. One is that unlike with other prescriptions, patients are less likely to ask the questions pharmacists are trained to answer—Is this an appropriate dose? Will it interfere with my other medications? Are there side effects or risks?—for the simple reason that they are in pain and therefore less likely to care about anything but resolving it—the sooner the better.

“The heart wants to be compassionate with a person in pain,” Hogue says. “But I think what has happened over time is that we’re in a society that expects an instant result. In almost everything we do in life, we expect instant results. We go to an ATM and get money instantly. We go to a drive thru at a fast-food restaurant to get food instantly. And when we’re in pain, we want it to go away instantly. So as consumers, oftentimes we will go to our healthcare providers and say, ‘I don’t care what you have to do; I don’t want to hurt anymore. And opioids are in fact effective at eliminating pain in the short term. But what opioids are not good at doing is correcting whatever the underlying problem is that’s causing the pain.”

Another problem is that it’s impossible for a pharmacist to know how much pain the patient is actually experiencing, which would greatly affect whether or not the dosage is appropriate, wildly out of proportion or even miswritten.

“Pain is experienced differently by every person,” he says. “We all have different thresholds for pain and different descriptions for pain. Unlike high blood pressure, which you can measure very easily with a device and tell that a patient’s blood pressure is high or low or normal, with pain it’s a much more complicated scenario. It’s not so easy to measure.

“But the reality is that real people experience real pain. And it’s something that you nor I nor anyone else can really gauge accurately, because we’re not walking in their shoes.”

But Hogue is a strong advocate for educating patients on alternative pain-management strategies, particularly after an initial trauma has passed, and he says McWhorter students are trained to offer suggestions about alternatives to prescription drugs, particularly those that come with risk of addiction. Depending on the situation, Hogue believes physical therapy, for instance, can be very effective for assessing the source of pain and teaching patients ways to treat it. He also believes over-the-counter pain medications, like plain-old ibuprofen or acetaminophen, are often enough to resolve a patient’s pain—whereas having a Vicodin or Percocet lying around only increases the temptation to self-medicate inappropriately. In fact, encouraging patients to get rid of prescription opioids once they are no longer needed is another goal of pharmacists and others trying to fight the problem, because no good comes from having leftover prescription painkillers sitting in the medicine cabinet “just in case”…or creating unneccesary temptation for others who can access it.

As Nelson puts it, it’s all about pharmacists wanting to do their job to the best of their ability and educate the public about what they put in their bodies.

“Pharmacists are not just pill fillers,” he says. “There are a lot of judgment calls that we have to go through to protect the public. There are so many different types of drugs—not just opioids and controlled substances—that we go to school and study, and many more that come out every year that we’re constantly learning about to make sure the population is treated appropriately.”

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