Clamped down

As a neighborhood pharmacist, owner-operator of a small drugstore on the west side of Chico, Ahmed Mamane develops close relationships with his customers. He remembers specifics about their medical histories; he knows about their lives. He cares about them individually.

Mamane understands what someone experiences when suffering from chronic pain. There’s more to the affliction than physical distress: The person can’t do a lot of things he or she used so do, he said, leading to feelings of weakness, uselessness and depression.

For decades, physicians readily prescribed painkillers—notably, opioids, such as codeine, morphine, hydrodocone (i.e., vicodin or norco) and oxycodone. Pain was considered “the fifth vital sign” until the Joint Commission—U.S. health care’s accreditation body—in 2002 reconsidered that phrase in its pain standards; even so, opioid prescriptions continued to rise, with U.S. sales nearly quadrupling since 1999.

Addiction and overdoses have increased correspondingly, to epidemic levels. Daily, an average of 115 Americans die from an opioid overdose. The National Institutes of Health also report approximately 25 percent of patients who use these pharmaceuticals abuse them and approximately 10 percent develop an opioid use disorder (i.e., addiction).

Butte County has a statistic even more dire: a death rate 2.5 times higher than the state average (4.5 per 100,000 residents).

In response to the crisis, agencies such as the U.S. Centers for Disease Control and Prevention (CDC) have issued recommendations to physicians and pharmacies on prescribing. Dr. Andy Miller, Butte County’s public health officer, championed a similar effort locally that resulted in community prescribing guidelines for primary care and emergency room doctors. (See “An uphill battle,” Healthlines, Nov. 2, 2017.)

Those protocols are voluntary. Packing more punch: crackdowns on pharmacies. The U.S. Drug Enforcement Administration (DEA) and California State Board of Pharmacy have laser-focused on the amount of opioids dispensed as well as the documentation and rationale. Penalties can include loss of license.

As a result, doctors increasingly get calls from pharmacists questioning prescriptions, and patients who’ve never had problems with painkillers find themselves impeded.

“I feel their pain,” Mamane said one recent morning, on a brief break between customers at KindCare Pharmacy and Medical Supply. “So I hope the government will find a better way to deal with” the opioid crisis than restricting patients’ access to drugs prescribed responsibly.

“We’re trying to get people off these pain medications all of a sudden—it’s hard. I feel it from just the encounters with my patients, and I don’t fill too many pain medication [prescriptions] here.”

Mamane worked for a chain before opening his Walnut Street pharmacy two years ago. One such big-box store—the Walgreens on East Avenue—hit the headlines in late June over opioids. The DEA, making its first-ever inspection of that Walgreens, determined it had bought twice as many narcotic painkillers as any pharmacy in the area, an amount five times greater than the national average, since 2015.

Investigators could deem Walgreens’ inventory level as warranted. Miller confirmed it’s Chico’s only 24-hour pharmacy; for patients discharged from Enloe at night, where else to fill an urgently needed prescription? That’s a possible mitigating factor.

Miller also pointed out that the drugstore installed one of the state’s first dropboxes for unused pharmaceuticals—the only one in Butte County (see “Taking back the drugs,” Newslines, May 5, 2016). Overall, he said, regarding the investigation, “I don’t have enough information to defend or accuse.”

The CN&R spoke with Walgreens’ corporate media relations officer, requesting an interview, but received no reply by deadline.

Before starting his job with the Butte County Public Health Department in 2016, Miller was medical director at Northern Valley Indian Health (NVIH), where he practiced family medicine for 14 years. He and his colleagues established a prescribing policy for opioids at NVIH clinics—different from guidlines at unaffiliated offices and hospitals where doctors determine how they practice, within medical standards of care.

“You can’t create policies for a community, but you can create guidelines,” Miller said. “When I started in this role, I had seen the benefit in the smaller scale and hoped collectively with the buy-in of physicians we’d see the benefit on a community-wide scale.”

Those who helped craft the guidelines set a goal of reducing the county’s total prescription amount of opioids—measured in morphine milligram equivalents (MMEs)—to the national average. Butte County was 3.5 times higher when he started, Miller said, and about two times higher now. The guidelines went out in January.

“Even before the guidelines, prescribing was coming down, so it’s hard to know how much is due to the guidelines,” he added. “But when we’re in a crisis like this, you take it on every front you can.”

Pharmacies represent a significant front. Miller noted that “pharmacists already were concerned and motivated” before county physicians coalesced around prescribing guidelines, “and lately we’ve seen a lot more regulatory authorities come down and question the volume of opioids and potentially the handling of opioid patients in pharmacies. So I see why they’re concerned.”

Legally, pharmacists have what’s called the “corresponding responsibility” of proper dispensing to physicians’ proper prescribing. Both Miller and Mamane explained that a pharmacist is expected to verify a prescription when he or she detects something unusual, such as a high dose or early refill.

“There used to be a culture where we could not question the doctor’s decision,” Mamane said. “They [would] think we step into their domain. We don’t. It’s still going to be their decision if they want it to be filled, but it’s our decision to not fill it also if we think there’s something wrong about the prescription….

“It’s a tough time for everybody,” he added. Miller agreed: “It’s hard on patients, it’s hard on prescribers and it’s hard on pharmacists.”

Miller said multiple studies demonstrate opioids’ effectiveness for treating pain acutely (short term) but diminishing effectiveness for treating pain chronically (long term) along with higher risks of negative consequences (opioid dependence, overdose). For other medications, he continued, that data would speak for itself; “this one is charged because all of us want to be compassionate and treat pain; want to help people.”

Patients cut off from medication, or cut down drastically, without an opioid replacement such as suboxone or buprenorphine “will not feel good if they don’t get the opioid,” Miller said, “whether [experiencing] its withdrawal symptoms or withdrawal pain; the mechanism is such that you will feel more pain if you’ve been on an opioid.”

Considering the scope and toll of the epidemic, he concludes that “our alternative is not great.”