Efforts to curb the nation's opioid epidemic have led some pharmacies, such as those at Walmart and Sam's Club, to enact new policies limiting the dosage and supply of the medications dispensed to some patients, despite what the doctors prescribed.
Pharmacists and others in the prescription drug supply chain say they are just doing their part to end a crisis that led to the deaths of 32,000 people in the United States in 2017 and sent countless more to hospitals and treatment centers.
Physician groups and patient advocates are concerned about Walmart's opioid policy that limits the dosage and supply of the prescription drugs pharmacists can dispense. They say management of a patient's pain should be handled by doctors, not pharmacists.
As part of a multipronged approach to address opioid overuse and abuse, Bentonville-based Walmart said in early May that its pharmacies would begin limiting first-time opioid prescriptions to a seven-day supply or less, depending on applicable state laws. Introduced at all Walmart and Sam's Club pharmacies over a 60-day period, the policy also restricts the daily maximum dosage patients can receive to the equivalent of 50 morphine milligrams.
CVS Health, the nation's largest pharmacy chain, implemented a similar policy in February. Medicare and Medicaid also are changing their coverage limits for opioids prescribed for acute pain. In addition, 32 states to date have adopted laws limiting the supply and dosage of the drugs that can be prescribed and dispensed. Most exempt patients have cancer or are receiving end-of-life or palliative care.
Walmart and Sam's Club operate 4,473 pharmacies in the U.S., according to a June market research report. According to Sam's Club's corporate website, it operates 566 pharmacy locations nationwide. CVS has 9,207 stores.
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In an emailed response, a Walmart spokesman said the company adopted the new policy and dispensing limits because "the health and safety of our patients is a critical priority."
The spokesman said the seven-day initial fill policy for those with acute pain aligns with U.S. Centers for Disease Control and Prevention recommendations made in a March 2016 report. That research found the group most vulnerable to addiction to opioids is those in acute pain, often from recent injury or surgery, and taking pain medication for the first time.
Patients with chronic pain or refilling prescriptions are less likely to become addicted. Taking an initial acute prescription for longer than seven days increases the risk of addiction, according to the CDC, and the risk of overdose rises at dosages higher than 50 morphine milligram equivalents.
The Walmart spokesman said that the company understands there may be instances where the need to manage a patient's pain outweighs the risk of addiction or overdose. "We will continue to empower our pharmacists to work with their patient's prescribers and use their professional judgment (to the extent they can within the confines on an applicable law) in those cases."
The American Pharmacists Association supports these policies in their emphasis on the pharmacist's role. On its website, it states that while any effort to address prescription drug abuse must balance patient needs with the need to prevent abuse, "pharmacists' knowledge, accessibility and expertise puts them in a unique position to help combat this epidemic."
A spokesman for the association pointed out a section of its policy supporting "recognition of pharmacists as the healthcare providers who must exercise professional judgment in the assessment of a patient's conditions to fulfill corresponding responsibility for the use of controlled substances and other medications with the potential for misuse, abuse and/or diversion."
DOCTORS WEIGH IN
The American Medical Association has taken a number of steps to combat the opioid crisis. One of these is the formation of an opioid task force. This group encourages doctors to take continuing medical education or other courses on opioid prescribing, pain management, addiction and other related topics.
Dr. Patrice Harris, chairman of the American Medical Association's opioid task force and the association's president-elect, said physicians are writing fewer prescriptions for opioids, and that drugs such as heroin and illegally obtained fentanyl now account for the most deaths and overdoses. She has said the association has concerns about laws and pharmacy policies that regulate how doctors treat pain. Association members believe those decisions should be made by doctors based on a patient's needs.
The association supports other measures such as prescribing non-opioid medications when possible or alternative treatments like physical therapy when appropriate; using state prescription drug monitoring programs; providing comprehensive treatment for substance abuse disorders; co-prescribing naloxone to patients at risk of overdosing; and encouraging safe storage and disposal of opioids and all medications.
WHO'S TO BLAME
More than 200 lawsuits have been filed nationwide by cities and counties seeking reimbursement for the costs of handling opioid-related deaths, emergency services and substance abuse treatment. The law firms of Crueger Dickinson LLC and Simmons Hanly Conroy represent the plaintiffs in most of these lawsuits, all of which claim pharmaceutical manufacturers deceptively marketed the drugs. The suits also claim prescription drug distributors and pharmacies failed to maintain effective controls over their distribution.
The Healthcare Distribution Alliance, the national trade association representing pharmaceutical distributors, takes issue with being characterized as part of the problem.
Responding to a recent court filing, alliance Senior Vice President John Parker said in an email: "The misuse and abuse of prescription opioids is a complex health challenge that requires a collaborative and systemic response that engages all stakeholders. Given our role, the idea that distributors are responsible for the number of opioid prescriptions written defies common sense and lacks understanding of how the pharmaceutical supply chain actually works and is regulated.
"Those bringing lawsuits would be better served addressing the root causes, rather than trying to redirect blame through litigation," Parker said.
Like the other stakeholders striving to curb the opioid crisis, the distributors recognize the need to work collaboratively to attack the problem from all fronts.
In February, the alliance joined other groups representing the pharmaceutical industry to form a national education and awareness initiative called Allied Against Opioid Abuse. The collaborative effort aims "to engage providers, pharmacists, and the public in education about the rights, risks and responsibilities associated with prescription opioids," according to a news release announcing the initiative.
"We all have a role to play in developing and advancing meaningful and responsible solutions to address the serious and complex issues raised by the opioid abuse epidemic," said John Gray, alliance president and chief executive officer.
Business on 08/04/2018