Okay, maybe it seems that I am obsessed with writing about the 90-day supply. I have long maintained that our ability to care for a patient is directly correlated with the frequency we see them. Only seeing a patient every 90 days is often not frequent enough to enable quality care. But today, I hope, even strong proponents of mail order and the 90-day fill will agree that 90-day mail order fulfillment of narcotics is a really bad idea. Let’s begin today’s edition of Tales from the Counter.
Recently, while working to fill a prescription for generic Percocet (Oxycodone / Acetaminophen), the insurance rejected the claim. The claim response indicated that the prescription was filled by a mail order pharmacy about 40 days ago. Like most mail order prescriptions, it was filled for a 90-day supply.
Seeing this reject made my blood boil. The anger I felt was not because I lost business to an out of state pharmacy that provides a drugs as a commodity instead of providing personalized patient care. We see medications offered as an inexpensive commodity far to often, and getting angry about it doesn’t help. I was angry because of the implications of mail order, 90-day supplies of narcotics.
Maintenance Therapy
The most common argument for the use of mail order pharmacy and 90-day supplies is that they are appropriate for maintenance medications. Once a patient’s therapy has been optimized and is stable, longer periods between monitoring by both the prescriber and the pharmacy may be acceptable. Medications for high cholesterol, for example, would be reasonable 90-day candidate. Once the patient has been dosed on the appropriate statin intensity level and labs have been checked (e.g. liver function tests), then it may be appropriate for the pharmacist to assess the patient for adverse drug reactions every few months. Other medications commonly promoted for mail order and 90-day supplies, though, may be less clear cut. Medications for diabetes and blood pressure, for example, certainly can benefit from more frequent monitoring by the pharmacist, and may not fit the 90-day model as well.
But are narcotics maintenance medications? I argue that while a patient might be dependent on opioid pain medications, and chronically using them, the treatment of even chronic pain should always be regularly monitored by both the prescriber and the pharmacy. The 90-day supply, quite frankly, isn’t conducive to this level of monitoring, and the lack of oversight is a significant concern. Also, there are major concerns that opioids are overprescribed and overused and the 90-day supply increases the potential risk of this medication-related problem.
Besides monitoring issues, the potential for diversion also becomes a significant concern. This ties in with the epidemic of narcotic abuse both here, in the United States, and worldwide. Narcotics delivered by the mail or currier services are at significantly higher risk of diversion. Unlike a retail pharmacy, where the patient and their caregivers are often known, a mail carrier or currier is at a significant disadvantage. HIPAA rules mean that the currier cannot know what the medication is or even that this is a narcotic. And while they may have to secure proof of delivery, the person accepting the delivery is generally unknown to the currier. Add to this the large quantities involved with extended day supplies, and the opportunities for diversion become even more significant.
Previously, we wrote about narcotic diversion and the responsibilities of the pharmacist in a blog entitled Pharmacy Street Blues (Link). Most of the methods pharmacists use to detect forged or counterfeit narcotic prescriptions rely on the pharmacists relationship with both local prescribers and the patients. A narcotic prescription doesn’t have to be forged to be illegal, either. There are prescribers writing for narcotics that are not following the DEA guidelines. Being a local provider makes it much easier to recognize this type of behavior. Any pharmacy without a local storefront, is going to be at a significant disadvantage in spotting both forged and illegally prescribed controlled substance prescriptions. Patients with pain issues need to have a team of providers who are communicating closely with each other to ensure appropriate patient outcomes.
The other side of the narcotics epidemic is what is sometimes called fringe prescribing. These are narcotic prescriptions that are legally prescribed but probably not fully compliant with the prescriber’s responsibilities according the DEA. Spotting these problems and addressing them is very difficult when you are dealing with a local prescriber and patient. State run Prescription Monitoring Programs are an important tool, but these documents, which show the patient’s controlled substance history at all state pharmacies and from all prescribers, are difficult to interpret due to frequent inaccuracies. Having a local relationship with the providers makes the process of spotting real and potential issues possible.
Obviously, controlled substances prescriptions are being mailed, and this practice is legal. Pharmacies participating in this practice are certainly aware of the issues and likely have some safeguards in place to minimize issues. The problem is that distance creates a large impediment to performing all of the necessary due diligence. With the large volume of prescriptions mail order pharmacies process, it is not hard to imagine that problems are more likely to slip through. It is my opinion that the risk associated with mail order narcotics outweighs the convenience of the service. Your comments are welcome below.
