//Opioid Abuse and local policy changes: Rants.
To those of you who don’t know much about me–which, let’s be honest, is probably most or all of you–I’m a pharmacy technican. A CPhT, if we’re getting fancy.
I love my job.
And not in the way that my coworker says it everyday, “IlovemyjobIlovemyjobIlovemyjobIlovemyjob.” She says it to be funny, but sometimes you kind of mean it. Sometimes you fill over five-hundred prescriptions in a usually slow-er retail pharmacy and stand at the register all day with a line and the drive-thru pinging over and over and over…
I’m not saying this in a self-convincing mantra that will somehow make my job any better. I’m not even saying it to be funny, because “Ha-ha, Poppy. Who really can whole-heartedly say they actually love their daily grind?”
… I didn’t think I would.
To be honest, I was working a dream-job under a local, professional photographer in my small hometown. But you know how small businesses go these days… They were running low on work hours and money, and I got the shaft.
To be fair, I wasn’t the best employee. I tend to let my ego get in the way of work when I get used to a certain routine. Not to say I was bad, I just… wasn’t hard-working. I started making mistakes that cost the company money… and even a few dollars here and there really amount to big sums over time.
So, I was a high-schooler who was bum out of a job. At this point in time, I was a senior in high school and I had no idea what to do with myself. I was pretty sure I was gonna go to school to do some research biology, do neuropsychology, or become a librarian. I’m a broad-spectrum kind of person.
The last thing I wanted to do was to return to the grocery store where I bagged two years before in my crummy-part-time-courtesy-clerk position. No fun. But, I needed a job.
That’s for another discussion, but I’ve always been a seriously independent person. Despite my parent’s (love you, single-Dad. You rock.) insisting that it was seriously okay, I was just in high school–not like I had to pay any bills or anything–I’ve just never been the person who could not work, when perfectly able to. Besides, college.
So, when I was “grabbed up” by an old friend who worked in the pharmacy, I thought I would hate it.
Boy was I wrong.
You know those things that you never try until the last moment and you find that you have a crazy passion for? Yeah. It was one of those.
My state is one of the worst for opioid overdose. Even before Prince died, we’ve had a serious problem. So, even just before Prince died and we got a state-wide standing order to prescribe Naloxone, I was on-board fully on wanting to be that pharmacist that won’t take a prescription from a doctor (even if they scream and threaten my career and fluff their chest feathers about being a more adequate medical professional) when I know it will literally kill the patient (… sad, but true story.)
So, I love my job. There is literally nothing more satisfying than fixing a prescription, solving a tough insurance problem, and learning so many new things on a daily basis. There is no better rush for me.
Sure, it has its ups and downs. Customers/Patients that will never be happy, for instance. Doctors, Nurses, and even patients that talk down to you like you haven’t worked in pharmacy for years… (doesn’t matter if you work there for 3 years or 50, let’s be honest…)
But it’s one of my favorite things, honestly. I love helping people. I love making people smile. I love solving problems. I love learning. I love horrible puns and dumb dad jokes. Perfect setting for all of those things.
So… Let’s talk about a.) my passion and b.) what’s frustrating right now.
If you don’t know much about the opioid abuse problem in the United States, here’s what the CDC says:
Since 1999, the number of overdose deaths involving opioids (including prescription opioids and heroin) quadrupled.2 From 2000 to 2015 more than half a million people died from drug overdoses. 91 Americans die every day from an opioid overdose.
They also say:
Every day, over 1,000 people are treated in emergency departments for misusing prescription opioids.8
Nearly half of the opioid overdose deaths involve a prescribed opioid.
So, my state is trying to get its shit together to avoid overdose and death. Good stuff. I’m really happy about a lot of this. I’m very very passionate about this. Especially Naloxone.
Naloxone Rant (you’ve been warned):
There’s a standing order by my state’s “state head pharmacist” or somesuch, that basically goes like this: “I have put my signature on thousands of prescription pads that prescribe Naloxone. Use them. Offer it to everyone. Elderly. Child. Pet. Everyone.”
Now from the surface, this may sound like a bad idea. But you have to know a little bit about it. First off, if the person is not having an overdose caused by opioids, it does not affect the patient. Not in the least.
So if your two-year old grandson, Billy, gets into the Naloxone, but not the meds you’ve so carefully locked in a safe, he giggles and runs away, with you scolding him the whole way. It will not affect anyone unless there is the presence of opioid overdose.
Secondly, it completely blocks the receptor and pulls the person from the overdose nearly immediately. That’s not pleasant. Not at all. It triggers instant physical withdrawals that get ugly.
But, here’s the thing: It’s not just for druggies. A common misconception is that all opioid overdoses are because somebody is intentionally and recreationally abusing their drugs. And while maybe many of these overdoses are of that sort, a lot of them aren’t.
Consider Granny. Granny is in her late 80’s. She has awful arthritis and has a hip and a knee that Medicare aren’t approving a replacement for because she’s simply too old. She probably lives by herself, but her children are trying to move her to a home where she can be better looked after by professionals. But the pain is getting to be too much. The doctor prescribes Norco. She’s opioid naive, so it’s a low dose. Pretty standard. (Actually, I imagine the doctor may prescribe something a little stronger, but this is all figuratively speaking.) Granny has a particularly bad day. She forgets that she took her pills earlier. She takes them again. And again. And again. She appears in the obituaries a few days later.
Consider Polly. Polly’s six. She loves visiting her great-uncle, Rob. Rob is a battle-worn vet who was discharged from the military after losing his leg to shrapnel. Even after the leg was amputated, the man is still struggling with chronic pain of the spine. Polly finds what looks like candy in a funny looking bottle. She decides that it’ll look very adult-like if she pops a few in her mouth. She stops breathing.
Spot is a normal dog. Spot likes to get into things….
You get the picture?
Naloxone has pretty standard dosing for all of the above parties, including the Jill and James who go on their benders on Saturday nights to just feel good but take it too far.
I’m not a pharmacist. I’m not a nurse, or a doctor, or any of that sort. I count pills and enter prescriptions and give you your change at the counter. I do not have the certification nor licensure to recommend anything. (I’ve even gotten a good wrist-slap for telling a patient that “No really, the generic Neosporin you’re looking at has all the same active ingredients as the brand name Neosporin.” If you can believe it.)
But naloxone gives you the chance to get emergency medical help. Naloxone doesn’t fix the problem–it allows time for medical personnel to arrive.
It’s pretty simple to use too: It’s administered as a nasal spray (rather, the kind my pharmacy has the standing order for has little apparatus that you can put on the syringe that flings the juice as a mist, it’s also an injection, I believe.)
And in the case of a recreational overdose, by the way, (and I know there are loopholes for this, but generally…) charges are the last thing you need to worry about. If you call 911 and tell the operator that someone is having an overdose–besides the standard “Where are you?”– there will be no charges. No investigation. No incrimination.
Besides, saving a life is the most important thing.
Whew. So that was the naloxone rant. It’s super important to me. If you have children or pets and take medication to manage your chronic pain, think about it, okay? Most insurances cover it at no cost as a prescription (Pretty sure all government-funded insurance plans, for instance.). And there are generally programs that can get it to you cheaply.
So why does my job kinda suck right now?
My state is jumping into a CDC action plan to eliminate opioid overdose in the next six months. My store (and corporate chain within the state.) is being proactive and putting it into place now. Great. I’m all for it.
Restrictions on opioid medication have always been tight. My pharmacy, in particular, is literally not allowed to fill any earlier but two days earlier. Some pharmacies will not allow you to wait until the next day to pick it up if you drop it off. You must always present a valid, government-issued, photo ID both at drop-off and pick-up. Most prescriptions are required to be prescribed by one office–one doctor–hard-copy prescriptions need to be picked up every month at the doctor’s office (some people need to go in every single week to get their prescriptions.) If you forgot that you ran out, you’re out of luck. And let’s not even talk about vacation overrides. Traveling with C-II (a category most opioid pain medications fall into) prescriptions for more than three weeks, unless perfectly timed, is practically impossible. Every single opioid prescription you process is entered into a state-wide (sometimes country-wide) monitoring system. (So that patients can’t fill duplicate prescriptions, even at different corporate chain pharmacies.)
So what does this new plan say?
Before I continue, I want to make it clear that this is not (as far as my research has brought me) a country-wide thing in the United States. I do not know what other states are doing. This is a discussion of local pharmacy policy changes in MY state (which won’t even be in general-populace effect for another six months.) You probably won’t be affected by these changes at all. It’s not a Trump-thing. It’s not even really something anyone should go running out into the streets and protesting about.
Basically, as of last week, my state-corporate chain is limited and regulated by CDC recommendations of morphine equivalent doses per day. We’ve had to turn many of our pain-managed patients away from getting their regular monthly pain medication. Some patients have been taking four Hydrocodone-APAP 5-325 (Norco) tablets every single day for the last six years. (Actually, not too terrible of a dose. Pretty standard for chronic pain management as far as I’ve seen. Definitely on the high side of things, but still falls within the FDA’s limitation of daily acetaminophen intake.) We’re having our hand forced to refuse those prescriptions without explicit documentation from the doctor’s office… more on that in a bit.
There’s also this thing we’ve begun terming the “Trinity” that is also a red-flag that forces us to turn down regular customers (customers we’ve had for years.)
Many of the concoctions for people include a benzodiazepine (typically an anti-anxiety, for example.), a muscle relaxant, and the pain medication (generally opioid, controlled.)
So say you’re a vet, have chronic pain and PTSD.
Well… I hate to say it–if a muscle relaxant is in your nightly regime to help you sleep because your muscles are literally clenched around the area where you experience your chronic pain–you’re generally screwed, as far as the CDC regulations go. (However, that being said, in the cases where you have an opioid with a muscle relaxant, an opioid with a benzo, or a benzo with a muscle relaxant, you won’t be dinged; it will only affect you if you’re on all three types of medication.)
But here’s the biggest beef: The program is directed to nab opioid overdose in the prescribing process. So why not target doctors offices?
Many of the times that we are forced into a position to turn down a patient’s fill, no matter how loyal or how long the customer has been to or with us, and we contact a doctor’s office to relay a bit of information about the new policies that are being put into affect, we are met with hostility. Hands are thrown in the air. Voices raised.
There is so much paperwork we’ve had to do in the last few weeks with patients who are on these regimes for medically necessary reasons (Cancer, for instance.) from prescribers who are well-within their prescribing process…
The new routines are slowing down the pharmacy in ways that do not fit well with the corporate less-people, more-efficient vision as of late (y’know, cutting hours on pharmacy technicians (in particular) so as to get the best of the best who work the fastest and are the friendliest and are really the most efficient overall.)
Now, I’m no professional, but I think that the organization that says:
Providers wrote nearly a quarter of a billion opioid prescriptions in 2013—with wide variation across states. This is enough for every American adult to have their own bottle of pills.1
Should focus more on the doctors’ offices than the out-patient, retail pharmacy.
But maybe I guess it does make sense: We’re the last stop before the medication gets to the patient.
Countless times a day, we need to call a doctor’s office to make sure they wrote what they think they wrote. A lot of the time, doctor’s offices (and particularly pharmacies, too.) don’t have a full-chart of what medications a patient is getting. This happens when a patient moves from one place to another. I, personally, have intercepted (luckily only a few) prescriptions written for Nitroglycerin (meant for heart-attack) on patients that have had a recent history of taking ED drugs (i.e., Viagra.) –a mistake that can kill the patient.
How many times have I specifically asked a patient who was receiving a Sulfa-antibiotic or a penicillin prescription whether or not they were allergic to the major ingredient, and have to jump on the phone to berate the doctor’s office of the fact that they didn’t note the allergy and to please-please-PLEASE send something that won’t have the patient in the emergency room that night?
(A few things you can learn about this: Please give FULL DISCLOSURE to your doctor’s office. Even when you’re visiting and just get a really bad case of bronchitis. It saves everyone a lot of grief.)
That being said, there are a lot of really great doctors and nurses–just be aware that they are human and are subject to mistakes–we all are. Pharmacies themselves are far from perfect.
Nonetheless, it doesn’t distract from the frustration that pharmacies are forced into the front-lines on this new CDC regulation policy enforcement.
I guess there’s one good thing that comes out of this, besides (hopeful!!) opioid overdose prevention: Patients can’t use the drive thru to get their controlled substance medications anymore.
So… if you live in a state where these CDC changes are taking place and are being affected by it, please be patient with your doctors’ offices and local pharmacies. Please be understanding that while it may sound “Crazy.” and “Insane,” please be aware that, generally, we’re doing the best we can to ease the frustration of the transition.
For everyone, be patient with the prescription filling process: It’s going to take us a lot longer to get your prescription out to you. Whether or not it’s under the new regulation rules. Even if you need to pick up your blood pressure medication. This is due to endless patient counseling of those who are affected by the new policies in place, endless angry phone calls, endless paperwork filling and calculating.
We can make this work beneficially for the future. It will take time for everyone to settle into a routine. Believe me, it’s just as frustrating for me as it is for you. (I don’t get paid any more to turn down your prescription.)
As always, thank you for your patience. Always high-five your pharmacy technician, it makes us feel appreciated. 🙂
What do you feel about your pharmacy? Are these CDC regulations affecting you? I’d love to hear from the peanut gallery on your experiences with pharmacy.
And of course, thanks for getting this far in my rant. ❤ Love and appreciate you all. I’ll probably post some Merrikh backstory here tomorrow.