Prescription Drug Abuse

Jennifer Richter, Pharm.D. Candidate 2015, UMKC School of Pharmacy, Columbia Campus

Jennifer Richter, Pharm.D. Candidate 2015, UMKC School of Pharmacy, Columbia Campus

With the FDA recently reporting about the rescheduling of hydrocodone combination products to CII, it brings attention to a topic that is an increasing problem: prescription drug abuse. In 2011 alone, the Centers for Disease Control and Prevention (CDC) reported that “about 1.4 million emergency department visits involved the nonmedical use of pharmaceuticals,” with many of the medications reported as anti-anxiety, insomnia, and benzodiazepines.1 The CDC also reports that prescription opioid abuse costs the US around $55.7 billion annually in lost productivity, healthcare costs, and criminal justice costs.1 In Missouri, health care providers are writing 95 pain killer prescriptions per 100 people, which in relation to the rest of the US, is average.1 Even more disturbing, in 2010, one in every 20 people over the age of 12 reported using prescription painkillers without a medical need.

Young Adults

Prescription drug abuse affects people of all ages, and is something that is difficult to predict. A survey conducted in 2010 by the Substance Abuse and Mental Health Services Administration (SAMHSA) concluded that people ages 12-25 years report the highest incidence of nonmedical prescription drug use.2 The same survey showed that “2.7% of 8th graders, 7.7% of 10th graders, and 8.0% of 12th graders had abused Vicodin.”2 While this might contribute to the argument that the rescheduling of hydrocodone products will eliminate this problem, the SAMHSA survey also has some statistics about OxyContin, which currently has the same CII scheduling that hydrocodone containing products will occupy; in fact “2.1% of 8th graders, 4.6% of 10th graders, and 5.1% of 12th graders” had experimented with OxyContin according to the 2010 survey.2 This may indicate that the scheduling of these medications does not limit access as it should.

Medicaid Fraud

A review of five states (California, Illinois, New York, North Carolina, and Texas) conducted by the Government Accountability Office in 2006 and 2007 “found 65,000 instances of Medicaid beneficiaries improperly obtaining potentially addictive drugs at a cost of about $63 million.”2 The same survey also found thousands of instances in which prescriptions were written for patients that were dead or were called in by people posing as prescribers.2 One area where rescheduling hydrocodone products may help is prescription fraud. As a CII, prescribers and nurses may no longer call in prescriptions for hydrocodone products, and handwritten prescriptions must be brought into the pharmacy in order to be filled. Patients may also be “locked-in” with pharmacies in order to be sure patients do not fill prescriptions at multiple locations however, “doctor-shopping” may still occur; and without a prescription drug monitoring program, the full extent of abuse may not be recognized.

Prescription Drug Monitoring Program

49 out of 50 states in the United States have implemented an operational Prescription Drug Monitoring Program (PDMP); Missouri is the last state withholding from the national movement of creating a program that would make illicit use and abuse of controlled substances much more difficult. The aim of a PDMP is to help with the legitimate prescribing of controlled substances, to prevent diversion and/or abuse, and to identify public trends in use and abuse of controlled prescriptions.3 Having a state-wide system that logs dispensed controlled substances allows for prescribers and pharmacists alike to have knowledge of their patients’ filling habits, and would also allow for suspicious activity to be checked by health professionals. The fact that Missouri is alone in having no operational PDMP makes us susceptible to illegal activity within our own borders; it also creates access for patients crossing state-lines to take advantage of the lack of oversight. Although many of the opponents of a PDMP fear the invasion of privacy that a logging system imposes, the implications of increased drug abuse and misuse and the need to continue the legitimate prescribing of medications used in chronic pain should impede those fears.

Without a PDMP in place, physicians and pharmacists lack information that would help the fight against prescription drug abuse, and patients who use those same medications for a legitimate purpose are scrutinized because of controlled substance use. Missouri needs to take a step in the right direction, and join the rest of the nation by putting a PDMP in place to put a damper on prescription drug abuse.

Jennifer Richter, PharmD Candidate 2015
University of Missouri – Kansas City, MU site
MPA Rotation Student, August 2014


  1. Centers for Disease Control and Prevention. Prescription drug overdose. July 3, 2014. Accessed August 27, 2014.
  2. Kirschner N, Ginsburg J, Sulmasy LS. Prescription drug abuse: executive summary of a policy position paper from the American college of physicians. Annals of Int Med. 2014; 160(3) 198-213.
  3. Drug Enforcement Agency. Prescription drug monitoring program: questions and answers. October 2011. Accessed August 28, 2014.

The Million Hearts Initiative

MPA Jennifer Richter

MPA rotation student Jennifer Richter.


Cardiovascular disease is the leading cause of death in America with around 800,000 deaths yearly.1 Americans also suffer from over 2 million heart attacks or strokes every year, and the damage is nearly $444 million dollars to our health care system and losses in productivity.1 Therefore, in 2011, the Department of Health and Human Services and several federal, state, and local agencies collaborated on the Million HeartsTM initiative to target cardiovascular disease.1 The goal is to use both clinical and community interventions to prevent a total of 1 million heart attacks and strokes by 2017.2 This goal works in concert with the American Heart Association’s much more aggressive goal of preventing approximately 4 million cardiac events by 2020.2 These lofty goals show how important it is to collaborate on health quality measures with other professionals for the benefits of our patients.

The aim of the Million HeartsTM initiative is to impassion patients to care for their own heart health through healthy diet, exercise, and medication adherence, and to also get clinicians to target guideline indicated goals for measures of heart health.1 The Centers for Disease Control and Prevention (CDC) is recommending the use of four markers to promote better health: aspirin use when indicated, blood pressure control, cholesterol control, and smoking cessation (ABCS).1 The initiative also attempts to enhance health through policies: improvement of clinician reporting of goal-directed measures within the Physician Quality Reporting System, increasing insurance coverage of preventive services, and distribution of grant funding to implement local services to reduce chronic diseases through education and screenings.2 This is a massive undertaking for these agencies and requires the work of every health care professional to ensure all targets are met.

Several organizations in Missouri have teamed-up with the Million HeartsTM campaign, including the American Heart Association, the American Stroke Association, the Missouri Department of Health and Senior Services, the Missouri Primary Care Association, Primaris, and your very own Missouri Pharmacy Association.3 They have worked together to create some guidance on how providers and pharmacists can help achieve the 2017 goal. Since community pharmacists do not have access to health records and labs, it’s important not to over-step the physician-patient relationship when trying to assess medications for individual patients. However, pharmacists should be available for open conversations with patients about goal achievements, the meaning of blood pressure and cholesterol numbers, diet and exercise, and barriers to medication adherence.3

  • Appropriate aspirin use: Aspirin use is not for everyone and the benefits must be weighed against the risks for every individual patient. The US Services Preventive Task Force has issued a recommendation on aspirin use that is gender and age specific.4 Many patients will pick aspirin up from over the counter, and this can be an important discussion to have with a patient, who can then discuss the recommendation with their doctor.
  • Hypertension: According to the CDC, 1/3 of all Americans have hypertension, which equates to nearly 67 million people, and only 47% of those have their blood pressure under control.5 It is important for pharmacists to be educated on the new hypertension treatment guidelines to offer the most up to date information when needed by prescribers. It is also imperative to spend time with patients who need help controlling blood pressure. Some patients may need help with medication adherence and taking medications at the proper time of day. Some patients may not be able to understand what the diagnosis of hypertension really means or how it can affect their health. Other patients may need that extra push into incorporating a healthy diet and aerobic exercise into their daily routine. Whatever the issue, increased time with our patients allows our patients to realize that we are willing to help them, which will increase the likelihood of their return and willingness to discuss their health.
  • Hyperlipidemia: According to the CDC, 71 million Americans have been diagnosed with high LDL and only 1/3 of those patients have their condition controlled. New guidelines for cholesterol management were released in 2013, and it’s important to note that these guidelines have done away with targeted goals and have suggested statins for first-line use.7 With this is mind, pharmacists should be ready to indicate the previous goals and to supplement physician knowledge with the new guidelines and how these differ. These are also important to take into account for discussions with patients, as their medications may have recently changed without much preamble from their doctor to reflect the new guidelines. As with hypertension, indicating proper diet, exercise, and medication adherence is appropriate for these patients as well.
  • Smoking cessation: In 2011, the CDC reports that 19% of the adult population were smokers.8 Studies have shown that even a brief clinical encounter with a patient discussing smoking cessation increases the rate of successful cessation by 50%.1 Pharmacists should be prepared to offer counseling sessions and insight to nicotine replacement products to assist patients in a difficult journey. It’s important to familiarize yourself with the tools at your disposal to assist your patients in becoming ready to quit.

Using the ABCS that have been set forward by the Million HeartsTM initiative, health care professionals can assist and empower patients to better care for their own health in a way that is manageable. More opportunities exist for pharmacists and physicians who are looking for other ways to expand the reach of the Million HeartsTM campaign, because together, we’ve got a million hearts to save.

Jennifer Richter, PharmD Candidate 2015
University of Missouri – Kansas City, MU site
MPA Rotation Student, August 2014


  1. Freiden T, Berwick D. The Million HeartsTM initiative: Preventing heart attacks and strokes. N Engl J Med. 2011; 365:e27.
  2. Tomaselli GF, Harty M, Horton K, Schoeberl M. The American Heart Association and the Million HeartsTM initiative: a presidential advisory from the American Heart Association. Circulation. 2011; 124:1795-1799.
  3. Primaris. Million HeartsTM in Missouri pharmacy champion role. June 2012. Accessed August 15, 2014.
  4. US Preventive Services Task Force. Aspirin for the Prevention of Cardiovascular Disease, Topic Page. October 2013. Accessed August 18, 2014.
  5. Centers for Disease Control and Prevention. High blood pressure facts. July 7, 2014. Accessed August 18, 2014.
  6. Centers for Disease Control and prevention. Cholesterol fact sheet. July 26, 2013. Accessed August 18, 2014.
  7. Stone NJ, Robinson J, Lichtenstein AH, Bairey Merz CN, Lloyd-Jones DM, Blum CB, McBride P, Eckel RH, Schwartz JS, Goldberg AC, Shero ST, Gordon D, Smith Jr SC, Levy D, Watson K, Wilson PWF. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults. Circulation. 2013.
  8. Centers for Disease Control and Prevention. Trends in current cigarette smoking among high school students and adults, United States, 1965–2011. November 14, 2013. Accessed August 18, 2014.



Multi-Disciplinary Patient Safety Conference

MPA Rotation Student Jennifer Richter

MPA Rotation Student Jennifer Richter

Last week, I had the opportunity to attend the Missouri 2014 Joint Regulatory Patient Safety Conference, held on Thursday, August 7, in Columbia. This was a conference sponsored by the Missouri Dental Board, Missouri Board of Nursing, Missouri Board of Pharmacy, and the Missouri Board of Registration for the Healing Arts, to promote patient safety across multiple disciplines, and to encourage communication among fellow practitioners.1 For those who couldn’t make the conference and would like the materials or topic information, continue to check back with the Board of Pharmacy website and materials should be available soon.

The day was packed full of informative topics including many ways to enhance our patient’s safety through communication and collaborative efforts. Many of the speakers encouraged inter-disciplinary communication and teamwork as not only ways to reduce the rate of medical errors, but to also empower patients to be involved in their own care. Communication was also mentioned as a way for practitioners who have experienced a medical error to begin to recover from the guilt associated with the error. Encouraging open communication lines across disciplines is an important step in protecting our patients and ensuring complete medical care.

The profession of pharmacy has often-times been seen as a profession that stands behind a counter to dispense pills. Often times the clinical skills we possess are not completely understood or utilized by our patients. However, the times are changing, and pharmacists are now being included in patient-centered discussions that occur in health institutions and our status as being formally recognized as health care providers is on the move. This collaboration of multiple experts including physicians, nurses, pharmacists, and others is important for the health of our patients; and it’s important to assert our role as medication experts.

As pharmacy students, we are infused with the idea of collaboration and the importance of patient advocacy, and institutional learning helps us gain insight to what types of problems we may encounter in the real world. I was lucky enough to have the opportunity to work on an inter-disciplinary team while in school, and it afforded me the appreciation that having a team with different mind-sets can positively impact the patient’s care as a whole. In school, we are taught how to manage chronic disease states, to offer preventative health such as immunizations, to tailor health plans to our patients, and to open up lines of communication with our patients’ providers. And while it may be daunting to begin to update how our profession is viewed from the outside, it is important to back-up our function on the patient care team with some evidence on how we can improve patient safety.2

Either in school or during subsequent training, we gain the knowledge to help our patients manage chronic conditions to improve quality of life. One such chronic condition is diabetes. The Asheville diabetes project famously showed how the utilization of the cognitive services pharmacists provide can significantly improve the quality of life of patients suffering from chronic disease.3 This project also demonstrated the cost lowering-effects inclusion of a pharmacist can offer: with better management of a disease, health care costs are significantly decreased.3 Another study compared how the addition of the pharmacist to primary care helped improve long term health in diabetic patients.4 At 12 months, of those with a pharmacist added to the patient care team: 62.6% had reached goal HbA1c <7%, 85% had achieved goal LDL-C <100mg/dL, and 61.9% had reached goal systolic and diastolic blood pressure <130/80mmHg; all markers were statistically significantly decreased from baseline.4 The study suggested that adding a pharmacist to the primary care team would improve long term markers, and in turn long term goal achievement.4

The ICU setting is no different. In a review of literature, it was noted that not only do patients subjectively define care as better when a pharmacist is part of direct patient care, but the physician also rated the care as “higher than that of desirable or optimal services.”5 It was also noted within the paper, that the addition of pharmacists to antimicrobial therapy services (in multiple studies and situations), reduced the time it took to initiate optimal therapy, reduced hospital stay, and reduced the rate of adverse effects and mortality.5 The paper also looked at anticoagulation services, analgesia and sedation protocol implementation, and emergency response, and with the addition of a pharmacist to the team, “patient safety and clinical outcomes are enhanced.”5

As the patient safety conference had demonstrated all day, communication is the key. It’s important that our patients realize the benefits of keeping their pharmacist up to date in changes made to their medication regimen; community pharmacists are in a unique advantage to be involved in point-of-sale conversations to offer education. It’s also important to communicate to providers that the evidence points to the safety advantage of the addition of the pharmacist to the care team, whether this be through inclusion on rounds, or via telephone conversation pertaining to medications. Through collaboration and communication, together we can improve patient safety.


  1. Department of Insurance, Financial Institutions, and Professional Registration. Health profession boards team up to sponsor patient safety conference. July 10, 2014. Accessed August 11, 2014.
  2. Alldredge AB, Koda-Kimble MA. Count and be counted: preparing future pharmacists to promote a culture of safety. Am J Pharm Educ. 2006;70(4): 1-3.
  3. National Business Coalition on Health. The Asheville project: recognizing the pivotal role pharmacists can play in chronic disease management in local communities. 2011. Accessed August 11, 2014.
  4. Ip EJ, Shah BM, Yu J, Chan J, Nguyen L, Bhatt D. Enhancing diabetes care by adding a pharmacist to the primary care team. Am J Health-Sys Pharm. 2013;70:877-886.
  5. Preslaski C, Lat I, MacLaren R, Poston J. Pharmacist contributions as members of the multidisciplinary ICU team. CHEST. 2013;144(5):1687-1695.

Tramadol Becomes Schedule IV on August 18, 2014

On July 2, 2014, the DEA published in the Federal Register the final rule placing Tramadol into Schedule IV of the Controlled Substances Act. This rule will become effective on August 18, 2014. All regulatory requirements applicable to Schedule IV controlled substances will apply to Tramadol beginning August 18, 2014. The final rule is available online at

Acknowledging that changes such as these take time to implement, the DEA extended the usual effective date for this type of change from 30 to 45 days to provide what it considers to be “reasonable time for registrants to comply with handling requirements for a Schedule IV” drug, such as moving Tramadol products into a warehouse cage or adjusting suspicious monitoring systems to include Tramadol orders.

All manufacturers will be required to print the designation “C-IV” on every bottle and it is unlawful for commercial containers of Tramadol to be distributed without that designation. In addition, all DEA registrants will be required to take an inventory of all Tramadol stock in compliance with 21 C.F.R. §  1304.11(d).

Drug Enforcement Administration (DEA) will make all Tramadol-containing products Schedule IV CS on August 18, 2014. Pharmacist should be aware:

  • An inventory is required to be taken on this day of all affected products. The inventory should be kept with the most recent CS inventory.
  • Schedule IV physical security requirements will apply.
  • The six-month/five refill limits will apply.
  • According to the BNDD, existing prescriptions and refills from mid-level practitioners who do not have CS authority and DEA/BNDD registrations will become void.

*Source: Drug Enforcement Administration, Office of Diversion Control, Drug & Chemical Evaluation Section

National Immunization Awareness Month

Welcome to August! This is a busy month for many people, as it is time to revel in the last few weeks of summer and to prepare yourself or your children for school. As pharmacists, it is also an important month to establish changes in our scopes of practice within Missouri: August is National Immunization Awareness Month. Governor Nixon recently signed into law Senate Bill 754, which expands the ability to provide vaccinations under protocol. With this addition, pharmacists will be able to provide not only influenza, pneumonia, shingles, and meningitis vaccines under protocol, but also hepatitis A, hepatitis B, diphtheria, tetanus, and pertussis vaccines.1 In this exciting time of expanding opportunities, it’s important to not only prepare your pharmacy for the upcoming changes but to also advocate for your patient’s health care.

To become more familiar with the new vaccines and to re-familiarize pharmacists to the immunizations they already administer, some statistics are provided within this article about the national rate of immunizations. Healthy People 2020, a national initiative by the US Department of Health and Human Services, has set multiple goals to improve the health of the American population by the year 2020. A portion of the goals Healthy People 2020 are based around the intent to increase the rate of multiple types of immunizations and to reduce the rate of vaccine-borne illnesses.2 Pharmacists will be equipped to help our patients acquire certain immunizations that will put us on track for a healthier future.

  • The National Immunization Survey in 2013 of teens aged 13-17, found that nationally 86% of those surveyed received one dose of Tdap since they were 10 years old, while in Missouri, 81.5% of those surveyed received a Tdap.3 Healthy People 2020 would like that number to be 80%, indicating that Missouri is right on target.2 Now that pharmacists will be able to administer diphtheria, tetanus, and pertussis vaccines, we should be able to further increase those numbers to stay on target for the 2020 goal.
  • Hepatitis A and B are addressed in the Healthy People 2020 objectives as well, and a reduction in the development of new cases is targeted.2 Both hepatitis A and B are multi-dose vaccinations, and community pharmacists are likely to see their patients more often than at a doctor’s office, and pharmacists can be available to remind of an upcoming scheduled dose.4
  • Healthy People 2020 would also like to decrease the rates of pneumococcal infection for those over the age of 65. In 2008, 60.1% of the population 65 years and older had received a pneumococcal vaccination; the goal for 2020 is 80%. In addition to the pneumococcal vaccination, Healthy People 2020 is targeting the shingles vaccine in patients 60 years and older. In 2008, 6.7% of the population 60 years and older were vaccinated against shingles; the target for 2020 is 30%.2 Pharmacists in community settings have a unique advantage to access to patients over the age of 60 who may either rarely visit the doctor’s office or who may run out of time to visit with the doctor, and with some questioning the pharmacist can ascertain the status of pneumococcal immunizations. Pharmacists may also be able to identify those patients under the age of 65 who may have risk factors requiring a pneumococcal vaccination.
  • Of note for adolescents soon-to-be college-bound or others with risk factors or certain medical conditions, Healthy People 2020 would like to reduce the rate of meningococcal disease.2  According to the CDC, approximately 600-1000 people per year contract the disease; although this number isn’t staggering, the disease itself can be life-threatening.5 Those recommended to get the vaccination tend to be healthy individuals who may not be visiting the doctor very often. Having availability to a pharmacist outside of an appointment is a great way to meet the Healthy People 2020 goal.
  •  Last, but not least, on the list of the Missouri pharmacist administered immunizations: the influenza vaccine. Healthy People 2020 would like national rates of vaccination to increase. In Missouri, 46.4% of the population received an influenza vaccination during the 2012-2013 flu season, with the national average just below at 45%.6 The goal set for the general population is a 70% vaccination rate. Healthy People 2020 has set an even loftier goal for healthcare workers, with a target vaccination rate of 90%.2 Patients are generally aware that their local community pharmacist is equipped to administer the influenza vaccination, however many patients tend to brush off the need for the vaccine. Rand Health conducted a survey in 2011 to determine the attitudes of Americans not receiving the vaccine and found that many patients simply don’t feel they need the vaccine. Other popular responses included: not having time, not believing in the vaccine, and thinking that they may become sick from the vaccine.7 As health care professionals, pharmacists have a duty to their patients to help explain the need for the influenza vaccine. The CDC website also has handouts and brochures available for health professionals to distribute to patients.

Healthy People 2020 sets national goals for Americans that are achievable if all healthcare professionals work together to promote patient advocacy. Pharmacists in Missouri have just been armed with more tools at their disposal to ensure that patients are appropriately vaccinated; and although we may not be able to offer every vaccination, community pharmacists are uniquely positioned to provide patients with information about their health they may not otherwise receive.

Jennifer Richter
MPA Rotation Student, August 2014
University of Missouri – Kansas City, MU site
Doctor of Pharmacy Class of 2015



  1. Missouri Senate. 97th General Assembly. Second Regular Session [Truly Agreed to and Finally Passed] Conference Committee Substitute for House Committee Substitute for Senate Substitute No. 2 for Senate Bill No. 754. 2014. Accessed August 5, 2014.
  2. US Department of Health and Human Services. Healthy People 2020 Topics and Objectives: Immunization and Infectious Disease. topicsobjectives2020/overview.aspx?topicId=23. Accessed August 5, 2014.
  3. Missouri Department of Health and Senior Services. National Immunization Survey: Teen (13-17 years old). Accessed August 5, 2014.
  4. Bridges CB, Woods L, Coyne-Beasley T. Advisory Committee on Immunization Practices: Recommended Immunization Schedules for Adults Aged 19 Years and Older; 2013.
  5. Centers for Disease Control and Prevention. Meningococcal Vaccination. April 1, 2014. Accessed August 6, 2014.
  6. Centers for Disease Control and Prevention. 2012-13 State and Regional Vaccination Trend Report. Accessed August 6, 2014.
  7. Adamson D. Rand Health Organization. Seasonal Flu Vaccine: Why Don’t More Americans Get It? 2011. Accessed August 6, 2014.