An Open Letter Supporting the Pharmacy Community

August 31, 2018

On Monday, Fox News reporter Geraldo Rivera ran a story on the opioid crisis. As part of his story, he accompanied the Drug Enforcement Administration (DEA) on a “raid” of four community pharmacies in Celina, Tennessee. Before I begin, I do want to clarify that I have no information regarding the accusations being made against the pharmacies and pharmacists in this case, and therefore have formed no opinion regarding their professional judgment.

However, there are numerous inaccuracies and misstatements in this story, including an inference that pharmacists were “prescribing” these opioids. This statement demonstrates a lack of general understanding of each provider’s responsibility regarding opioid medications. Rivera’s story also does not convey the important work being done by TPA member pharmacists and pharmacy professionals to make a difference in patients’ lives. Most concerning is the lack of recognition and acknowledgment for all the work that has been done, and continues to be done, by the pharmacy community to curb prescription drug abuse in Tennessee.

We know our country is facing a prescription drug abuse crisis. We also know that drug overdose deaths in Tennessee are on the rise, despite the fact that prescriptions for opioids in the United States have decreased 22 percent between 2013 and 2017. Many of these deaths from drug overdoses are caused by mixing prescription drugs with illicit drugs like heroin and illegally-obtained fentanyl. Regardless of the offending substances, we hurt for those who have lost loved ones to prescription drug overdoses. We hurt for those who are dependent or addicted to prescription drugs. We hurt for those who don’t have affordable access to addiction treatment options. We hurt for our patients who suffer from legitimate pain and are caught in the crossfire of this terrible prescription drug abuse epidemic. The pain experienced by many who find themselves or their loved ones suffering from dependence or addiction to prescription drugs is equally as difficult to grapple with as the legitimate physical pain that plagues many of our patients who are denied access because of increased regulatory barriers, drug shortages, and decreased access to care.

This story emphasizes the need for more in-depth discussions regarding the corresponding responsibility of pharmacists. According to DEA Rule 1306.04 Purpose of Issue of Prescription, the responsibility for the proper prescribing and dispensing of controlled substances is upon the prescribing practitioner, with the pharmacist having a “corresponding responsibility.” It’s not just pharmacists and prescribers who are being evaluated. The Tennessee Attorney General is suing pharmaceutical manufacturers of opioids. The DEA continues to crack down on the manufacturing of opioids. Congress has also scrutinized wholesalers and distributors for their role in this epidemic.

Pharmacists and pharmacy professionals continue to play an important role in leading prescription drug abuse prevention efforts in Tennessee. Here are some of the legislative issues that the Tennessee Pharmacists Association (TPA) and our members have worked to enact:

Controlled Substance Monitoring Act of 2001 – Championed by TPA and the pharmacy community and led by pro-pharmacy legislators, this law created Tennessee’s controlled substance monitoring database (CSMD).
Prescription Safety Act of 2012 – Pharmacists took a proactive role and assumed responsibility for checking Tennessee’s CSMD.
Addison Sharp Prescription Regulatory Act of 2013 – Pharmacists championed efforts to limit the dispensing of opioids and benzodiazepines in Tennessee to no more than a 30-day supply.
Protection for Pharmacists’ Professional Judgment – Championed by TPA and the pharmacy community and led by pro-pharmacy legislators, this Tennessee law established a pharmacist’s authority to decline to dispense to a patient a legend (“prescription”) drug which, in that pharmacist’s professional judgment, lacks a therapeutic value for the patient or is not for a legitimate medical purpose.
Prescription Drug Disposal Act of 2015 – Championed by TPA and the pharmacy community and led by pro-pharmacy legislators, this law authorized pharmacies in Tennessee to serve as points of access for patients to dispose of unwanted and outdated prescription drugs (including controlled substances).
Prescription Safety Act of 2016 – Pharmacists took a proactive role and assumed responsibility for checking Tennessee’s CSMD on a more frequent basis.
Statewide Naloxone Collaborative Pharmacy Practice Agreements – Championed by TPA and the pharmacy community and led by pro-pharmacy legislators, this law authorized pharmacists to dispense opioid overdose reversal agents (opioid antagonists like “naloxone”) to patients at risk (or individuals in a position to assist a person at risk) of an opioid overdose, through a statewide collaborative pharmacy practice agreement with the chief medical officer of the Tennessee Department of Health.
Penalty Enhancement Factor for Pharmacy Robberies – Championed by TPA and the pharmacy community and led by pro-pharmacy legislators, this law protects pharmacists, pharmacy staff members, patients, and citizens by deterring robbery-based offenses on the premises of Tennessee pharmacies.
TN Together – TPA was instrumental in working with legislators to amend Governor Haslam’s original TN Together legislation to ensure that legitimate pain patients maintain access to opioids while creating roadblocks to prevent future prescription drug dependence and abuse. Specifically, TPA championed efforts to facilitate the collection and reporting of ICD-10 codes (“diagnostic codes”) and reasons for prescribing, as well as the utilization of partial fills rather than multiple prescriptions to limit quantities of opioid prescriptions dispensed.
Authorization for Partial Fill of Controlled Substances – Championed by TPA and the pharmacy community and led by pro-pharmacy legislators, this law empowers patients and prescribers in Tennessee to voluntarily reduce the quantity of controlled substances through the partial filling of controlled substances.

Pharmacists, student pharmacists, and pharmacy professionals work hard to comply with state and federal controlled substance laws. Our members educate their communities and the public through the Generation Rx campaign. Our faculty and student pharmacists at our schools and colleges of pharmacy in Tennessee continue to lead the nation in research and practical application projects aimed at curbing prescription drug abuse. TPA has partnered with the Count It! Lock It! Drop It! campaign to increase patient access to pharmacy-based drug disposal options. Pharmacists utilize their professional judgment every day to determine whether or not prescriptions have been issued for a legitimate medical purpose. Often, difficult decisions not to dispense are made through collaboration with prescribers, with careful consideration of risks versus benefits of medication therapies. Statistics show that pharmacists check the CSMD personally and frequently, and we know that pharmacists have honest discussions with patients that others may choose to avoid. Calling the pharmacy profession the “last line of defense” is short-sighted. As a football fan, I know that a defense with only a defensive line and no supporting team members will lose 100% of the time. This fight against prescription drug abuse takes a full team to earn a “win” against prescription drug abuse, with every player working together as a unit.

Health care providers, insurers, law enforcement, regulatory agencies, community coalitions, wholesalers, distributors, manufacturers, patients, caregivers, and many other stakeholders must find a way to work together in a collaborative manner. TPA continues to work with all stakeholders to convey the value of pharmacists and ensure that the balance between appropriate patient care and prevention of prescription drug abuse is maintained. Through education and outreach, TPA has provided its members with numerous opportunities to gain essential knowledge related to the proper prescribing and dispensing of opioids through in-person educational sessions at live meetings, web-based training programs, and exclusive access to the members-only practice-based resource page on Opioids and Prescription Drug Abuse. These educational efforts are necessary to ensure that Tennessee’s pharmacy professionals are equipped to provide the highest level of patient care.

Each person who chooses to make a difference by contributing time, experience, money, and voice to TPA holds ownership in this organization and directly contributes to its success. TPA is all of us working together, and the future of pharmacy depends on us! Here are a few steps you can take to make your profession your priority today:

Engage local providers, community drug coalitions, legislators, and other stakeholders to convey the role you play in improving the lives of your patients
Take on a leadership role through elected office or committee service
Contact your professional colleagues and encourage them to join TPA to grow our collective professional strength

Your support for TPA and pharmacy is vitally important and greatly appreciated. TPA will relentlessly continue to advance, protect, and promote your right to provide high quality patient care in Tennessee.

Micah Cost, PharmD, MS
Executive Director
Tennessee Pharmacists Association