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Narcotic Medication: Trends, Fraud and What the Government is Doing About It

Prescription pain medication, classified as “narcotic analgesics,” are covered under drug formularies. Some plan sponsors will be surprised to learn that narcotic medications can be a significant part of their drug spend.

When Beneplan looks at drug usage reports for our benefits co-operative, we sometimes see narcotics at an unusually high amount. This could be abuse, but it could also be a controlled method of coming off an addiction.

For example, the drug usage report below is for a company of 40 employees. The employer was aware that two staff members were going through methadone treatment, meaning they had to go to a pharmacy every single day to be dispensed methadone. The company was charged both a dispensing fee plus a fee for the pharmacist to watch the patient take the drug.

Beneplan went to the Canadian Health Care Anti-Fraud Conference to learn more (Sept 21, 2012 in Niagara Falls). This article is based on the lecture conducted by Anne Resnick, Director, Professional Practice, Ontario College of Pharmacists. However, not all of the comments made here are associated with Ms Resnick’s remarks.

This lecture detailed how the National Narcotics Strategy would work on a tactical basis.

Ontario Narcotic use doubled in past decade

  • The government has classified “monitored drugs”: opiates, R
    italin, Valium, barbiturates, all forms of codeine (including Tylenol 1 and 2 which is over-the-counter)
  • The Ontario Drug Plan (ODB) spent $156M on narcotics in 2009-10 for 3.9 M scripts
  • There are 3,500 pharmacists in Ontario
  • Over the past 5-10 years, the amount of narcotics consumed has increased dramatically compared with the past. More deaths, overdoses, more crime, more abuse. Why? First, more are covered on the ODB formulary. Second, due to marketing by drug companies to doctors that these new pain killers are not addictive.
  • This has lead to an OxyContin crisis in first nations communities

The Crime Landscape for Prescription Narcotics

  • Pharmacists used to worry about a thief breaking in at 3:00am to steal drugs. Now, they worry about armed robbers on the spot during broad daylight for narcotics – this was unheard of in the past few decades.
  • Toronto saw double the crime from 2005 to 2008 for charges on selling prescription drugs as street commodities.
  • 2005-09, admissions to Government funded rehab doubled due to narcotics.
  • Happens even in ‘good neighbourhoods’ where you’d think it would never happen
  • Occurrences of internal theft as well (staff stealing drugs).
  • Pharmacists aren’t trained to deal with crime or theft in school
  • Prescription forgeries are also common.

Educating Children not to Raid Daddy’s Cabinet

  • There is a huge issue with high-school students taking medications from their parents’ medicine cabinets to a ‘candy bowl party’.
  • Candy bowl parties are events where guests all bring some drugs, put them into a bowl, and then grab anything and mix with alcohol.
  • Adolescents think it’s harmless because they are taking a legitimate prescription drug that won’t harm them

Do we have to be 100% pain-free?

Resnick commented that the general public has a school of thought in that all pain should be controllable and we should all be 100% pain-free, which health professionals say is unattainable.

OxyNeo

With the government getting away from generic OxyContin and implementing OxyNeo instead, Resnick doesn’t think the problem will go away. People with addictions need to be treated.

“If you cut off the avenue of a particular molecule, the problem will be just as big the next day,” said Resnick. “There may be a movement to a more harmful product. It’s a complex problem and we can’t slam the door on a drug unless we also implement a corresponding increase in treating addictions.” It’s the law of unintended consequences.

The Narcotics Monitoring System (NMS)

The government activated the Ontario Narcotics Monitoring System on May 14, 2012.

It’s a central database to enable reviews of monitored drug prescribing and dispensing activities within the community health care sector.

5 elements of the narcotic strategy

  • Development of a narcotics monitoring database
  • Educate on appropriate prescribing
  • Educate on appropriate dispensing
  • Educate to prevent excessive use of prescription narcotics
  • Treatment of addictions

The NMS checks for the following red flags

  • Double doctoring: a patient obtained monitored drugs from 3 or more different prescribers in past 28 days
  • Poly pharmacying: a patient obtained monitored drugs from 3 or more different dispensaries in the past 28 days
  • Refilling too soon: based on the day’s supply of the previous claim, a refill should not be required at this time. However, there is no set refill period for narcotics. A script could say, “for pain relief, take 1 or 2 tablets every 3 or 4 hours when needed. Take 2 at bedtime if needed.” So there is no strict timer period. It used to be instinctive, but now pharmacists actually enter in a number of days for which a script is used for.
  • Drug utilization review checks – if someone double-doctored or poly-pharmacied, then the NMS will issue an alert to the pharmacy in real time, at the time of dispensing.
  • The law says that if a patient gets a narcotic prescription from more than one prescriber, the patient is supposed to inform the other doctor. However, this does not always happen.

The NMS collects data for all “monitored drugs” regardless of how the Rx is reimbursed (private payer / ODB / Cash purchase). However, this data does not get sent to the 3rd party payer. It stays between patient & pharmacist who must exercise professional judgement in deciding what course of action to take if it looks like someone is abusing.

One concern with the NMS is that patients will hear about the new system and get scared that they don’t want their behaviour tracked. Some might not go to the pharmacy to pick up their pain medication any more because they think big brother is watching them. What they’ll do instead is something to be seen.

How much do narcotics cost?

The cost of narcotics can vary. It can be $2,300 for one dose of brand OxyContin, or $25 for one generic prescription Percocet. It ranges from 20c to $4/pill.

Now, more practitioners can prescribe narcotics

  • Podiatrists, midwives and nurse practitioners can now prescribe narcotics (opiate and synthetic opiate pain killers) and Valium in Canada (source). They can already prescribe certain meds which relate to foot disorders (ex: antibiotics, anti-inflammatories)
  • This was granted in Australia in 2009 (source)
  • The UK allowed podiatrists and physiotherapists to prescribe painkillers in 2012 (source)