Pharmacist Red Flags and the Idaho PMP Marcus C. Hurst, PharmD Retail Pharmacist Albertson’s/Save-On March 5 th, 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 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 1 Substance 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) Rockville, MD: Substance Abuse and Mental Health Services Administration, Substance 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. 3 UNODC, 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 One in Twenty Americans used pain killers for non- medical reasons in 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:

Assessment Question #1 The United States makes up ____% of the world’s population, but consumes ____% of the world’s prescription drugs? A.5 and 75 B.10 and 90 C.15 and 50 D.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 Website:

This Includes You Safe Prescribing Practices = Corresponding Responsibility Title 21 Code of Federal regulations Part 1306 – Prescriptions 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 B 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 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.Physician’s Assistant B.Pharmacist C.Nurse Practitioner D.Dentist E.MD or DO

Pharmacist Red Flags Most Common, Easily recognized Early refill requests What is the cut off? 80%? 90%? 30 day Rx: Same drug, different prescriber Dr. Shopping Multiple pharmacies How would you see this outside your own system CutoffUsedDays EarlyRefills/YearTabs/Year 80% % %

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 ( 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