Prescription transmission

Just before Christmas, sobering statistics from the Centers for Disease Control and Prevention drove home the pervasiveness—and toll—of prescription-drug addiction.

Drawing national headlines such as “Drug overdose deaths reach all-time high” (as trumpeted by CNN), the CDC revealed that 47,055 Americans died from drug overdoses the previous year. That represented a jump of 14 percent from 2013 and the highest total since at least 1970.

In the majority of those deaths (61 percent of cases), opioids, which include many painkillers, were involved. It doesn’t take much, says local pharmacy owner Janet Balbutin. “Bill Clinton was on TV with [CNN’s Dr. Sanjay] Gupta pleading to all the providers because he had lost a friend who had just one beer and one OxyContin and didn’t wake up in the morning.”And yet, she added, “the impact on the [hospital] ERs around the country has been so great because of these drugs.”

The U.S. Drug Enforcement Agency has attempted to stem the stream of prescription opioids by tightening regulation of the prescriptions themselves.

Physicians face greater scrutiny when prescribing these medications, and pharmacists must follow additional procedures when dispensing them. “There has been a clampdown,” said Dr. Roy Bishop of Argyll Medical Group in Chico. “But there has also been a change in clinical practice. It’s now considered less acceptable to prescribe high doses of narcotics over a long period of time, so there is pressure from government, from insurers, from pharmacists to cut down on the prescribing.”

Both physicians and pharmacists have safeguards—including a bit of technology befitting the Oval Office—to secure their information exchange. Indeed, high-tech security plays a major part in overdose death prevention, and Butte County is on the leading edge.

Until recently, the DEA did not allow physicians to send electronic prescriptions for certain controlled medications, even as federal government—through the Affordable Care Act—pushed medical offices and hospitals to digitize. Moreover, the DEA reclassified that list of controlled drugs (known as Schedule II) to include lower-concentrated opioids such as Norco.

The American Medical Association balked at the contradiction of paper prescriptions in a paperless age, so the DEA approved technology called two-factor authentication, which physicians in certain areas, including Chico, have given a trial run. It goes nationwide this year.

Two-factor identification means the doctor not only has to provide a log-in and password to access a prescription, but also must possess a special electronic device that generates a random number recognized by his or her computer as authentic. The device resembles a USB flash drive.

The prescription then gets transmitted to the pharmacy.

Bishop appreciates the added layer of security at his practice, describing it as “almost a military level of technology” like the president’s missile-launch encoder, “although I think the biggest safeguard is not being able to phone [opioid prescriptions] in. When I came to this country in 1996 [from Scotland], I was astonished that you could telephone in an order for a Schedule II narcotic.”

People still try, though. Balbutin says her pharmacies get bogus prescription calls regularly, though mostly for drugs on lower tiers of the DEA’s control list.

There’s a “fine balance” for Bishop and other physicians who prescribe pain medication.

“Doctors feel like we’ve been put in a very difficult situation,” he said. “We have to relieve pain, but if we use too many narcotics, we can be punished …. I do refer to pain management specialists if the patient’s needs are more than I’m comfortable with.”

Punishment can mean losing a medical license. The California Medical Board reports it has stripped the licenses of three doctors in Butte County for overprescribing.

Bishop said the goal is to ensure that “mainstream physicians” have controls in place, such as seeing patients regularly and monitoring their medications. A state database known as CURES (Controlled Substance Utilization Review and Evaluation System) helps doctors and pharmacists check on patients’ prescriptions to make sure they haven’t gotten the same script from another doctor, thereby “double-dipping” and having a large amount of pills on hand.

Balbutin has been a pharmacist since 1968 and operates the family-owned Chico Pharmacy, Chico Medical Supply & Ostomy and Paradise Drug and Medical Supply. She recalls the era before the recent federal efforts, when “doctor shopping” and the ready ability to pay for painkillers led one customer to bring an order for 2,300 pills.

“No way you could take that much in a month,” she said. “But they were able to get a prescription, and Medi-Cal was paying for it, or they paid cash. Now we can’t let them pay cash like that without a whole bunch of hoops; we can’t even dispense that much anymore. Three years ago, we were [able to].

“There’s an all-out effort by the DEA to reduce all this fraud, waste, abuse.”

Then, of course, come the people who attempt to steal opioids. Two nights before Christmas Eve, a man held up the pharmacy counter at the Walgreens on East Avenue for a “big bottle” of oxycodone, not cash. Balbutin said her drugstores have been broken into 15 times since 1993—most recently in December, prompting her to install bars on the glass doors and windows.

Neither she nor Bishop attribute these crimes to tighter controls, even if the rules have made it tougher for pills to hit the black market.

Nor is this an isolated issue. According to CDC statistics from 2014, California had the highest number of overdose deaths with 4,500; however, when adjusting for population size, the states with the highest rates were West Virginia, New Mexico, New Hampshire, Kentucky and Ohio.

Deaths from natural opiates (e.g., morphine and codeine) increased 10 percent from 2013, synthetic opioids (e.g., fentanyl) 80 percent.

In that context, the added scrutiny of pharmacists and physicians is particularly significant.

“It is a nuisance,” Balbutin said, “but it’s necessary.”