Category Archives: Pharmacy

Medications at High Risk for Diversion and Abuse In Correctional Facilities

The practice of Correctional Medicine has many strange differences from medicine outside the walls. It took me a couple of years to get comfortable with the various aspects of providing medical care to incarcerated inmates. Of all of these differences, one that stands out in importance is the fact that many seemingly benign medications are abused in correctional settings.

Of course, the Drug Enforcement Agency (DEA) has established a list of drugs known to have potential for abuse and even addiction. The DEA even ranks these drugs according to the severity of this risk. Schedule I drugs carry the most risk, followed by Schedule II, and so on, all the way down to Schedule V, which are thought to have the least risk.

However, the drugs that we are talking about here are not on the DEA’s list. These are medications that are not abused (or, at least, not thought to be abused) in mainstream medical settings. But these drugs are, in fact, abused and diverted in jails and prisons.

The reasons for this are somewhat complex, but in my mind, it boils down to this: These are drugs that have psychoactive effects that mimic, to some degree, the effects of the drugs on the DEA Schedules. If you are addicted, or even if you just like to get high once in a while, and you can’t obtain your preferred drugs of abuse because you are incarcerated, these are the drugs that can serve as an alternative in a pinch.

It is critically important for medical professionals in corrections to know which seemingly benign drugs have the potential to be abused and diverted. Even if a particular inmate doesn’t care about getting high himself, he can still profit by selling these drugs to others who are. Vulnerable inmates can be (and are) bullied into obtaining these drugs for distribution–if we make them available. Continue reading

Taming the Beast—Gabapentin. Ban It or Regulate It?

In my last post, I began with a question from Christy.  Her facility was considering banning gabapentin from their facility due to rampant abuse and diversion problems.  My last post dealt with gabapentin’s interesting history and the evidence base for off-label gabapentin prescribing.  This JailMedicine post will deal with the pros and cons of banning gabapentin versus creating rules to regulate gabapentin use and hopefully minimize diversion and abuse. Continue reading

Taming the Beast: Gabapentin

A reader recently wrote

At our facility, one of the most abused drugs in Neurontin. I am the trying to formulate when this medication will be continued. My question is if the following is acceptable in your opinion:
Neurontin will not be given for any indication not approved by the FDA. The only indications approved by the FDA is for epilepsy and PHN after shingles. Now the question remains how can you tell what the indication of prescribing the Neurontin was? The therapeutic dose for the treatment of epilepsy is 900 to 1800mg a day divided into three times a day not to exceed 3600 mg per day. If you come to our facility on 300mg at night, this clearly indicates that the drug was not given for the two recommended doses so therefore, it can be assumed it was given for insomnia- which we do not treat at our facility. The Neurontin would be canceled and we would observe for signs and symptoms of withdrawal for the next 5 days.
Does this sound reasonable and do you know of a substitution for the treatment of diabetic neuropathy that is less abused in the jail setting?
Christy

Well, you’re not alone, Christy! Gabapentin is one of the most abused and diverted drugs at all correctional facilities that I know of! (I’m going to use the generic term “gabapentin” interchangeably with the brand name “Neurontin” in this article). In fact, I was recently in a meeting with the commissioner of a certain state’s Department of Corrections to give an update on medical services in his prisons and the very first question he asked was about gabapentin. Gabapentin! Think of all the things he could have been concerned about—Hepatitis C for example—and instead, he asked about the security problems caused by gabapentin diversion.

In my experience, gabapentin is one of the “Big Three” non-DEA regulated drugs with the potential for diversion and abuse in a prisons and jail. The other two are Seroquel and Trazodone. The important difference is that Seroquel and Trazodone both allow easy substitution of another, less abused, cousin. Gabapentin, not so much.  More on that later.

In order to get a handle on gabapentin, I think it is important to understand where it came from and why it has not approved by the FDA for most of the reasons it is prescribed nowadays. B_beuRNW8AEYOgn

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Changes in Hypertension Treatment? Why Yes! The Recommendations of JNC 8

As we all know from long experience, hypertension is the single most commonly seen and treated condition in primary care medicine. It is an important risk factor for strokes, heart attacks, kidney failure and overall death. It has been exhaustively studied. And yet there is still significant controversy over hypertension, including how to define it and what the best agents for treatment are.
Against this background, The 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults was released last December in JAMA. It was written by the 8th Joint National Committee, and so, of course, is referred to as JNC 8.

JNC 8 has a couple of important and surprising changes from JNC 7. One of these, at least, is controversial enough that some members of the committee rebelled and released a dissenting “Minority Report” (apologies to Tom Cruise). Today’s JailMedicine post is a summary of JNC 8 recommendations and changes to JNC 7.20140430 Continue reading

Skeletal Muscle Relaxers Do Not Relax Skeletal Muscles!

Today’s post is an opinion piece. Personally, I think that skeletal muscle relaxers like cyclobenzaprine, methocarbamol and chlorzoxazone are over prescribed for acute and chronic musculoskeletal pain, both in the outside world but especially in corrections. The main reason for this, I think, is that prescribers misunderstand what muscle relaxers do. Contrary to their name, muscle relaxers do not relax muscles, at least as they are commonly prescribed. Muscle relaxers are sedatives, pure and simple, and should be prescribed with that fact in mind. Instead of telling patients (and ourselves) that “I am prescribing a muscle relaxer for you,” in the interest of full disclosure, we should be saying “I am prescribing a sedative for you.”  Continue reading

Should Inmates Bring Their Own Prescriptions to the Jail?

In response to my last post, one reader wrote to tell me that the jail where she works does not accept medications brought in by inmates or their families. They consider this a security risk.  All medications are ordered and supplied by the jail.  She asks if I will comment on this. Before I do, I need to define a couple of terms that come up over and over in any discussion of newly booked inmates’ medications.

Verification

UnknownThe first term is “Verification.”  Verification refers to the process of verifying what medications an inmate is currently prescribed and is taking.  There are three ways to verify medications.  The first is to call the prescribing doctor’s office to get a list of currently prescribed medications.  The second is to call the dispensing pharmacy to get a list of all prescriptions they have recently filled for the patient.  Finally, the inmate could bring the medications they are taking into the jail with them in the original pill bottles.  On the label is everything we need to know—who prescribed the medication, when it was filled, dosages–everything.

One problem with calling the doctor’s office to verify medications is that the patient often is not taking all of the prescribed medications.  If I remember right, studies show that only around half of all prescriptions are filled.  So you will get a list of prescribed medications, but that may not be what the patient is actually taking.  Another problem with calling the doctor’s office for a current medication list is that doctor’s offices are often closed.  If a patient is booked Friday afternoon of a holiday weekend, you may not be able to get a current medication list until Tuesday.  Finally, many inmates get medications from multiple prescribers.  For example, the patient may have a family physician, but a psychiatrist prescribes their mental health medications and they also use a pain specialist.  And get prescriptions also from ERs and “Doc-in-the-Box” clinics.

Calling the pharmacy may get you more information than calling the doctor’s office.  After all, the pharmacy will only tell you about prescriptions that were filled and can also tell you when the prescription was filled.  If you do call a pharmacy to verify meds, don’t just ask for an “active medication list!”  The pharmacy considers any prescription that they would fill for the patient active, and refills are generally good for one year.  So if a patient may not have taken a certain medication for many, many months, but the pharmacy still considers it “active.”

And like doctors’ offices, pharmacies may be closed when you want to call them.  And inmates often use more than one pharmacy.  Some inmates use mail order pharmacies that are hard to get any information out of.  Or an inmate may not use a pharmacy at all—for example, their medications might be supplied by a psychosocial rehab group.  Finally, it is not uncommon for an inmate not to remember what pharmacy they use, at all!

Authorization

The second term to define is “Authorization.”  I discussed medication authorization in my last post.  Authorization refers to the process of reviewing and inmate’s (verified) medication list and deciding which of those medications will be dispensed at the jail—and which will not.

All incoming inmates taking medications should have their prescription list verified and authorized.  These two processes take quite a lot of nursing time and effort at most jails.

So now we return to the original question.  Which is better, to allow inmates to bring their outside medications into the jail with them or not to allow this and instead verify their medication list and re-prescribe the approved medications ourselves?  The answer is that there is no “right” answer.  Each system has its advantages and disadvantages.  Which you choose to use at your jail depends on several factors, such as the size of your jail, your staffing levels and the sophistication and efficiency of your pharmacy system.

With that in mind, let’s compare each system as to its relative advantages and disadvantages with regard to some of our goals in jail.20130619

Continuity of Care

We want medical care to continue seamlessly from the outside to the inside of the jail.  We want there to be no lapses in ongoing medical care for newly booked inmates.  This means that, ideally, there will be no missed doses of important medications.  This is, of course, easiest to accomplish if inmates brings their medications to the jail in the original containers.  This makes verification, authorization and dispensing to the inmate a simple process.

Contrast this with what usually happens if the inmate does not bring the meds with them.  The current medication list must be verified with phone calls to the doctor’s office and pharmacy.  Even if this goes well (no offices are closed), the medications then must be ordered from the jail’s pharmacy.  Best-case scenario:  the process takes 24 hours.  More commonly, it takes 48-72 hours and the patient has been without medications for 2-3 days.

If the inmate does not bring meds into the jail with them, the only solution for timely administration of most medications is to have an extensive collection of “stock” meds on hand, so that most medications can be continued quickly from stock.  In order to be able to fill the majority of outside medication prescriptions, there must be a lot of stock meds plus protocols for automatic “therapeutic substitution”  (mentioned here).  http://www.jailmedicine.com/the-f-word-formulary/ That is a pretty sophisticated system.

However, even then, no “stock” med collection is going to contain all of the various HIV meds, say.  Or cancer chemotherapy agents.  And these are precisely the medications that we most want to continue without missing a dose!

Clearly, from a “continuity of care” perspective, it is better to encourage inmates to bring in their own, outside medications.

Advantage:  Allowing outside prescriptions.

Information Gathering

There is no question that having the original pill bottles sometimes gives you medically important information.  As one example, consider the patient who takes combination lisinopril/HCTZ for blood pressure.  He brings in a bottle that was filled 45 days ago for a one month supply (30 pills).  There are 29 left in the bottle.  His blood pressure is 128/78.  Would you continue the prescription?  I probably would not.  I would, instead, monitor his blood pressure to see if he really needed the medication.

Or say instead, his blood pressure is 180/120.  If I know that he has not been taking his hypertension medication, I would simply restart it in the jail.  But if he had been taking it faithfully, I might consider adding or changing the prescription.

I could give many more examples of similar situation.  Knowing that the patient has (or has not) been taking their prescribed meds is often very helpful clinically.

Advantage: Allowing meds to be brought in to the jail.

Time Management

The issue here is how long it takes nursing staff to verify and approve a newly booked inmate’s medications.  If the inmate brought meds to the jail in the original pill bottles, verification consists of noting the information on the prescription label, verifying that the medications in the bottle match the label and counting them.  Authorization is easy as a phone call to the provider.  And then the medications can be immediately dispensed to the inmate.

If the inmate did not bring meds to the jail, verification will take much more time.  It consists of interviewing the inmate (Who is your doctor?  Which pharmacy do you use?), then calling the doctor’s office, the pharmacy or both (hopefully, there is only one of each!).  If there is a discrepancy between what the inmate says they take and what the pharmacy says they filled, a second interview with the inmate may be required.  Then, after the approval process, the medications must be ordered from the jail pharmacy, delivered, processed and then, finally, they can be dispensed.

Advantage:  Allow meds to be brought in.

Cost Considerations

Consider the case of the inmate who is only going to be in jail for 30 days.  He is willing to supply his own medications for the month long stay.  Among other things, he takes Abilify, which costs approximately $25.00 a pill.  If your jail will not allow him to bring in his own Abilify, then you must either supply it at a cost of many hundreds of dollars for that medication alone, or substitute something else.  Even if patients are on inexpensive medications, these med costs and fill fees add up.

In addition, if your jail charges a fee to fill prescriptions, inmates will complain, because often they get their outside medications for “free” (meaning Medicaid, most often).  I have even had inmates go so far as to call this extortion and refuse to take jail prescriptions because they do not want to pay any money for meds that they are willing to supply “for free.”

Advantage:  Allowing meds to be brought in at booking.

Medico-Legal Considerations

The main medico-legal risk in these situations is disruption of the continuity of care, in this case, patients missing doses of important medications.  If (Heaven forbid!) something bad happens after the patient has missed a dose of medication—like the patient has a heart attack or commits suicide—it will inevitably be blamed on the missed meds by the patient, his family and their attorney.  I have seen this many, many times.

Advantage:  allowing meds to be brought in.

Security Considerations

This is the one aspect of the problem where there is a decided advantage not to allow outside medications into the facility.  Anytime you allow stuff from the outside to come into the jail, there is a potential for a security breech.

One possibility is that inmates might adulterate capsules by pulling them apart, pouring out the real medication and then filling them with cocaine, heroin or whatever.  However, this is not as easy to do as it sounds.  Adulterated capsules don’t look right and, in my experience, are quickly suspected and discarded.  Besides, if you want to smuggle illicit substances into a jail, there are easier methods than trying to pour powder into tiny capsules.

A more legitimate security concern is what to do with medications that were brought in to the jail but then were rejected during the authorization phase and so never dispensed to the patient.  Non-controlled substances can be placed in the patients’ property, but things can go wrong.  For example, the meds, somehow, are not there when the inmate is discharged from the jail six months later.  Where did they go?  The inmate, of course, may demand compensation for his lost property.  Maybe there should be an investigation?

Controlled substances are even worse, especially DEA schedule 2 drugs like methadone and amphetamines.  Like all schedule 2 controlled substances, these properly should be kept under double-lock (i.e., a locked box in a locked room) and should be counted every day with two people witnessing and signing off.  That is a lot of work should the patient stay in jail for a significant amount of time.   And when the inmate is released, you have this dilemma:  should you return these addictive controlled substances to him? What if he overdoses?  What is your risk exposure?

Advantage: not allowing out-of-jail medications in the facility.

In the end, which system you eventually put into place for incoming inmate medications depends on how important the security angle is to you and how well you can create and use a stock medication system.  To some degree, this depends on jail size.  The smaller the jail, the more important continuity of outside care becomes because the small jail’s medical staff may not be there all the time.  Large jails are better able to develop sophisticated stock medication systems where most incoming prescriptions can be quickly and easily filled from stock.  But even big jails should have exceptions in place for expensive specialty medicines, like chemotherapy agents, immune-modulators and HIV meds.

Does your jail allow incoming inmates to bring their medications to booking?  Do you like the system your jail uses?  Please comment!

Do Fish Oil Capsules Prevent Heart Disease?

Sometimes, good ideas just don’t turn out as we expect. This Interesting-Article-of-the-Week is one such case and is, perhaps, the death knell for fish oil capsules so long prescribed for heart disease.Capsule Continue reading

Beware of “Friendly Prescribing!”

doctor-with-prescription-padImagine that you are a healthcare provider in a jail medical clinic. One of the jail nurses comes to you and says “Will you call me in a prescription for my hypertension meds? I have no more refills and my doctor charges $100.00 for a visit just to get more!” Or perhaps it is a detention deputy who asks, “Can I get a few Ambien from you? This shift work kills me and I need them occasionally.” Or “Can I get some Augmentin? I have Bronchitis.”

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Understanding Pharmacy Prices. Can It Be Done?

20130206There are several good reasons to know what your pharmacy is charging you for each of the drugs you order. You need to know actual prices in order to assess the value of similar drugs, like two different first generation cephalosporins. In fact, you will have to know this in order to be able to set up a Pre-Approved Drug List. You need to know when a particular drug has a sudden price decrease or increase so you can switch to the most cost effective drug. Finally, you want to know that you are being charged fairly. If a pharmacy sells you a drug for 5% more than the price they paid to the wholesaler to obtain it; that seems fair. But if they jack up the price literally by 46 times, well, that does not go down so well. (See story below)!

Unfortunately, pharmaceutical prices are among the most convoluted and hard to understand of all drug prices. They are kind of like airline ticket prices. Have you ever heard of the game in which passengers on a commercial airline flight compare what each of them paid for their ticket with the lowest price being crowned the winner? (Their reward is the deep satisfaction that comes from knowing that everyone else is jealous of them). Airline tickets are kind of a unique item in the economy in that the price varies depending on many factors like when you book, how you book, how often you fly, how many bags you check and on and on.

Who Can Understand Pharmacy Industry Jargon?

Pharmacy prices are similar to this. What you pay per pill for drug X at your facility may be far different than what the facility down the street pays. The system is so convoluted, in fact, that it sometimes can be hard to even find out what your pharmacy is charging you and how they derive this price.

Pharmacies have their own professional jargon that can be hard for outsiders to understand—just like us! We say, for example, that a patient has an “erythematous urticaria” when we mean “itchy red rash.” Pharmacists say “I’m charging you the Average Wholesale Price minus 12%.” What the heck does that mean?

It turns out that there are many pricing systems in the pharmaceutical industry. You only really have to know about two of them, but it is worthwhile to peruse a list of the others:

Average Wholesale Price (AWP)
Actual Average Acquisition Cost (AAC)
Wholesale Acquisition Cost (WAC)
Average Manufacturer’s Price (AMP)
Maximum Allowable Cost (MAC)
Federal Supply Schedule (FSS)
Federal Upper Limit (FUL)
Estimated Acquisition Cost (EAC)
Average Sale Price (ASP)
Usual and Customary Charge (UCC)

And that is not all of them! The problem is that each of these pricing systems can give amazingly different prices for the exact same medication.

Fortunately, you only have to know about two of these pricing schemes; one that you don’t want to use and one that you do want to use. Forget about all of the others.

Average Wholesale Price (AWP)

The one that you don’t want to use is the Average Wholesale Price (AWP). Historically, this is the most common price system used by pharmacies. The problem is that it is a misleading term. You would think that the “Average Wholesale Price” would be the average price that the wholesalers charge for a drug. Well, you would be wrong. AWP is not a wholesale price and it is not an average. It is just a price set by the pharmaceutical industry. It is debatable exactly where that price comes from. However, AWP is, on average, 20% higher than the true wholesale price. But can be as much as 120% higher!  That means if a pharmacy says to you “I’m going to charge you AWP less 12%,” that means that they will be making somewhere between 8% and120% profit on these sales.  (They were probably smiling when they said it).  And that is in addition to their “Fill fee,” which I will discuss in a future post.

In addition to being an inaccurate representation of wholesale costs, AWP is quite hard for the typical consumer, like you and me, to find. You can’t just look up AWP online. AWP are listed in certain pharmacy trade publications like The Red Book, but access to the Red Book is quite expensive. And even if you get one, you will find that a certain medication, say ranitidine 150mg, has not just one AWP like you would expect, but a bewildering array of AWPs that range in price from one cent a tablet to well over one dollar a tablet. Some AWPs apply only to hospitals, some to huge bulk purchases like Wal-mart would make. It is often almost impossible to decipher what would apply to your situation. I know. I have tried.
Some pharmacies really like to use AWP and I can see why. It has many advantages for them. AWP overestimates wholesale costs to the advantage of the pharmacy. The pharmacy understands it, but you don’t. In essence, AWP is what the pharmacy says it is! How are you going to know differently? If possible, do not deal with the AWP!

Average Actual Acquisition Cost (AAC)

The price that you want to use instead is the Average Actual Acquisition Cost (AAC). AAC is an estimate of the actual wholesale cost your pharmacy pays for medications. Instead of being head-scratchingly hard to understand, AAC is easy to understand. It is the true wholesale price. And instead of being almost impossible to find out, you can find out the AAC in one of two easy ways. First, you can ask your pharmacy for the AAC of medications you commonly order. Some pharmacies will give this information to you, no problem. If you have a pharmacy like this, consider yourself blessed. Other pharmacies can be quite loathe parting with this information.

Fortunately, there is a second way to find AAC prices: You can look them up online. Most state’s Medicaid programs utilize AAC to set Medicaid drug prices and publish the AAC on their website. If your state does not offer online access to AAC, feel free to use Idaho Medicaid’s AAC website, found here.

How Much Difference Does It Really Make?

Is the difference between AAC and AWP really that important? Here is a true story that illustrates the difference.

Like many doctors, I have a little black bag with some doctor tools and medications that I can use in urgent situations. One such “stat” medication that I keep in my black bag is ondansetron (Zofran), which is, of course, used to treat nausea. A couple of weeks ago, I went to a local chain pharmacy to get some new ondansetron for my black bag. I had looked up the AAC online before I went to the pharmacy and found that the AAC of generic ondansetron 8mg tabs was 15 cents apiece. For 30 of them, the total AAC would be approximately $4.50. Figure in a percentage markup and a fill fee and I thought I would be charged approximately $10.00-$15.00 for this prescription.
Instead, the pharm tech looked me in the eye and said “That’ll be $235.43.” The pharmacy had calculated the price using AWP!

$10.00 vs. $235.43. Now that is the difference between AWP and AAC in a nutshell. What would your facility have done had it been charged $235.43 for this prescription? Paid it without question, I suspect.

So getting back to the original question: Is it possible to understand pharmacy prices? The answer is Yes! As long as you use the Actual Average Acquisition Price. You can understand the numerous other pharmacy pricing schemes only if you understand their relationship to AAC.

Do you have a good relationship with your pharmacy? What do you pay for your pharmaceuticals?  Please Comment!

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Interesting Articles of the Week: Prescriber’s Letter and Medical Letter

20121128The saying goes that just half of what we were taught in medical school is wrong.   Also half of what we think we know about medicine now is wrong.  The problem is that we don’t know which half!  But this does mean that keeping up-to-date with the current medical literature is very important.  Why just yesterday I read that maybe leeches and purging aren’t such good treatments for headaches after all!

Two of my favorite sources of continuing medical education are the Prescriber’s Letter (found here) and the Medical Letter (found here).  Both provide evaluations of medications and changes in medical thinking that are unbiased by marketing from Big Pharma.  Both are subscriptions services (which they have to be since they don’t accept advertising) but both are well worth the money.

Recent editions of both publications have some really interesting information that I would like to share here.  Because I don’t want to infringe copyrights, I will summarize the information presented instead of “copy and paste.”  Those who are interested can look up the originals!

Prescriber’s Letter, January 2013

Beta Blockers for Hypertension?  Not for most patients!

Beta-blockers are no longer a preferred drug for uncomplicated hypertension.  Even though they do lower blood pressure, beta blockers are less effective in preventing long term bad outcomes like heart attacks and strokes than alternative medications like  diuretics, ACE inhibitors/angiotensin receptor blockers (ARBs) or calcium channel blockers. Atenolol appears to be the worst offender in this regard.  The one population in which beta-blockers should still be used are those patients who have had heart attacks or otherwise have known coronary artery disease.  So if your patient has had an MI, use metoprolol or carvedilol.  If not, use something else for hypertension.  Get rid of atenolol entirely.

The Medical Letter, Dec. 24, 2012

Can you use cephalosporins in patients with penicillin allergies?  Yes, in most patients.

I was taught in medical school that patients with a true penicillin allergy had a 10% risk of also being allergic to a cephalosporin.  It turns out that this is not true.  The true incidence of allergic reactions to cephalosporins in patients who relate a history of penicillin allergy is only 0.1%.

There are two reasons for this.  First of all, if you skin test all people who say that they are allergic to penicillin, only a small minority will be found to be truly allergic (I have heard less than 10%).  Second, even those patients who are proven to be allergic to penicillin by skin testing have only a 2% chance  (not 10%) of also being allergic to cephalosporins.

Chemically, penicillins and cephalosporins do share a common beta-lactam ring, but it is the side chains of the molecules, not the central ring, that cause allergic reactions.

So if a patient has almost died from a penicillin allergic reaction, i.e, Stevens Johnson Syndrome or toxic epidermal necrolysis or the like, I would not risk the 2% chance of repeating the event.  But if the patient gives a history of a vague rash thought to be due to penicillin, the risk of using a cephalosporin is very, very low.

Do you still use beta blockers for uncomplicated hypertension?  Why or why not?  Please comment.

Do you give cephalosporins to patients with a stated penicillin allergy?  We would like to hear your comments!

I have only listed two of my many favorite resources for Continuing Medical Education.  What are yours?  Please comment.