Pharmacists Are Uneasy About Their Role in State Plan to Fight Opioid Abuse

By Hojun Choi

Reporting Texas

Texas lawmakers might consider forcing pharmacists to start using an online database designed to identify potential opioid abusers, but pharmacists say they would fight the proposal if it comes up in the legislative session that begins Jan. 10.

In its review of the Texas State Board of Pharmacy, the Sunset Advisory Commission reported that the state “lacks key tools needed to ensure safe dispensing of dangerous, highly addictive drugs to patients” and recommended that pharmacists be required to use the database, called the prescription monitoring program, any time they fill a prescription for pain management.

No bill has been filed yet that would make the change, but legislators take Sunset recommendations seriously, and the opioid abuse epidemic has gained prominence as a state and national issue.

The Sunset Commission pointed to the benefits of the monitoring program in reports on the boards of nursing, dental examiners, physicians and veterinarians. It suggested requiring podiatrists, veterinarians and nurse practitioners to check the database before administering opiods.

The database, created in 1982, keeps a record of prescriptions for habit-forming drugs. Law enforcement and healthcare professionals can refer to the database to check when and where the patient had similar prescriptions filled for a period of 12 months.

Opponents of the proposed changes, which would be implemented starting in 2018, told Reporting Texas that the mandate could undermine the professional judgment of healthcare providers.

“Technology, including the database, provides additional tools, but the ultimate professional discretion on drug therapy cannot be delegated,” said Audra Conwell, executive director of the Alliance of Independent Pharmacists of Texas.

Conwell, whose organization represents thousands of pharmacists, said they are trained to recognize signs of potential abusers.

“Independent community pharmacists know their patients and use their training, knowledge and experience to manage prescription drug therapies with the use of all dangerous drugs, including opioids,” Conwell wrote.

Sheevum Patel, manager of an independent pharmacy in West Austin, said using the database could clog the work flow of an average pharmacy.

Pharmacists already work under tremendous pressure because they are seen as the last line of defense against opioid abuse, Patel said, and they should not be the only ones who are holding that line.

“Doctors should be able to screen for these things, especially those in pain management,” Patel said. “They know what they’re writing for. They know how addictive these substances are.”

The 84th Texas legislature voted in 2015 to move management of the database from the Department of Public Safety to the pharmacy board. The board recently rolled out improvements to the database, but it’s too soon to tell whether the changes will overcome pharmacists’ complaints that the database is difficult and time-consuming to use.

Gay Dodson, executive director of the pharmacy board, wrote a letter to the Sunset Commission in June arguing that the recommended changes could have “unintended consequences,” despite good intentions.

“We would like the state to not mandate the query,” Dodson told Reporting Texas. “The system that was there before was hard to use and the usage dropped to terrible, terrible numbers.”

Austin Police Detective Troy Reeves said he became acquainted with the shortcomings of the database during his work in the narcotics division and on a Drug Enforcement Agency task force.

“I find it kind of ironic that in this technological age, we still don’t have a nationwide database,” Reeves said.

Peter Kreiner is a principal investigator for the Prescription Drug Monitoring Program Center for Excellence at Brandeis University. His job is to measure how well states use their databases and push for improvements.

“There is always pushback from both prescribers and pharmacists because of the time needed to check the database — especially in states where they have to log on to a separate system and do a query on each patient,” Kreiner said.

The urgency of the opioid health crisis, however, should “supercede” the argument that the database bogs down workflow, Kreiner said. Software improvements should help alleviate some of the difficulties Dodson mentioned, he said.

The National Association of Boards of Pharmacy has been looking into ways to make the platform more user-friendly, Kreiner said. “It’s an active area of study, but there is certainly not a gold standard. People recognize that it would be nice to have an easier interface.”

Other efforts include integrating prescription monitoring into electronic health records and pharmacy dispensing software, he said.

“In states that have put in requirements for both prescribers and pharmacists, there has been a big effect on reducing overall numbers of opioid prescriptions,” Kreiner said. “Nobody has singled out pharmacists, so it’s hard to say how effective that move would be.”

In 2014, the Texas Department of State Health Services told the Senate Health and Human Services committee that Texas was below the national average for prescribing opioids.

In April 2015, however, the Houston Chronicle and Austin American-Statesman reported that the number of prescription drug-related deaths was widely underreported by the state.

Mark Kinzly works in Austin to help addicts through the local chapter of the Harm Reduction Coalition. In addition to working face-to-face with addicts seeking sobriety, he serves on the board of directors of the national nonprofit organization.

“I certainly know of a lot of people who started on pain meds unaware of the potential of abuse,” Kinzly said.

In addition to shopping around for a doctor willing to write a prescription for the pills, addicts also seek drugs from outside the country through the internet or find street substitutes such as heroin or fentanyl.

Though he thinks the prescription monitoring program is a good idea, Kinzly said, fighting prescription opioid abuse requires a “multi-pronged” approach that includes recovery and rehabilitation services.

“It is almost impossible to get people into treatments that have physical addictions, and unless you have really good insurance and resources, it is almost impossible to get the help they need,” Kinzly said.

Vincent Valenti, 32, a veteran of the United States Air Force, is recovering from prescription drug addiction through Kinzly’s program. For Valenti, who was injured in combat, the drugs were more for his mental pain rather than his physical need for the medication.

“Being shot sounds bad, but I didn’t need much pain meds for it,” Valenti said. “You’d be surprised at what you can go through if your mental state is in a good place.”

Legal problems convinced Valenti to clean up his act. He began his program in Austin in January. Though he believes new regulations to fight opioid abuse are good steps, he doubts they will solve the problem.

“There are always going to be people who need it and get addicted,” Valenti said.