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Simple packaging change can reduce Rx drug diversion

We get a lot of complaints from consumers who tell us their pharmacy shorted them on the number of tablets or capsules they were supposed to get when they had their prescription filled. A report we got last week is typical.

We get a lot of complaints from consumers who tell us their pharmacy shorted them on the number of tablets or capsules they were supposed to get when they had their prescription filled. A report we got last week is typical. A young patient who had dental surgery received a prescription for the opral opioid Lortab 7.5 mg. The amount the dentist listed on the prescription was 24 pills. The patient's mom had the prescription filled at a local pharmacy. Then, later on at home she counted only 21 pills. Mom called the pharmacy because she wanted to make sure the pharmacist was aware that a mistake had been made in the count. But the pharmacist became defensive, even suggesting that her daughter must have diverted the pills.

Nearly all of the complaints we get like this involve opioid narcotic prescription products like Oxy-Contin, Vicodin, Lortabs, etc. The pharmacy always seems to say that the patient or someone in their home removed some tablets (either for themselves or even to sell on the street) and the patient says the same about the pharmacist and/or their staff. In truth, research shows that diversion through "shorting" (undercounting) and pilferage by pharmacists and pharmacy employees does take place and it's not that uncommon. At the same time, pill-abusing middle- and high-school students are often obtaining their drugs through medicine cabinet thefts. So really, it's essential that we find better ways to control these drugs.

The importance of preventing drug diversion is a constant concern. It came to light again last week when the CDC reported that drug overdose deaths in the US rose for the 11th straight year in 2010. There were 38 329 deaths with 22 134 (57.7%) involving pharmaceuticals. Three-quarters of those were unintentional and, not surprisingly, prescription opioid narcotics like those above were responsible for 75.2% of the involved drugs! It's time we took a hard look at the way these drugs are commonly dispensed in the US. We make it way too easy for people who abuse drugs.

In the U.S., community pharmacists dispense almost all oral solid drugs, including narcotics and sedatives, as loose tablets/capsules in a plastic vial that is labeled for the patient. It makes it easy to divert the pills because you can't prove in a quick glance how many are in the container. Drug control is far better outside the US where a system of packaging called patient packs or "unit of use" (a sealed patient package containing a quantity that is typically prescribed) is used almost exclusively. Manufacturers, doctors, pharmacists and computer system vendors have worked together to standardize the available quantities. Pharmacists don't have to count pills and they rarely ever hear from a patient about missing doses.

The manufacturer's unit of use package provides tablets or capsules enclosed in individual blisters in strips of 10. They are sold in sealed containers holding quantities typically required for dispensing a prescription. Inside, the pills are numbered so the quantity can be recognized at a glance even if the box has been opened. These are already available here for many drugs but unfortunately, pharmacists rarely use them.

If patient packs were used for oral opioids in the US, most of the count disputes would easily be eliminated and it would be much harder for drugs to be diverted. Patients and pharmacists would be able to readily identify the quantity of pills being dispensed and the patient could be asked to sign for and agree to the amount at the point of sale (as per amount printed on outside of the sealed container or the actual count). Such packaging would also help consumers in detecting home diversion by a teen or other person who has access to their home because the quantity remaining would be readily identifiable.

Unit of use packaging increases can increase safety in other ways too, including medication error prevention. Each blister strip has the drug name printed, which can help people spot a dispensing error, especially on prescription renewals.

The "patient pack" idea sure makes a lot of sense to me. To be sure, if you have a prescription filled and it isn't in a patient pack, consider counting the pills with the pharmacist while still at the counter. Maybe even ask her to document the count right on your receipt - with a signature. Also, if you suspect a problem, you should report it to the State Board of Pharmacy. If they see a pattern they can investigate.

Sadly, chain pharmacy corporations and independent pharmacy owners have not embraced the patient pack concept in the US. It's probably because it costs a few more cents per dose and also because patient packs would take up more storage space. Doctors would also have to prescribe only the quantities available in patient packs, which initially might cause some confusion. But given the crisis we're seeing with prescription drug abuse, I see this as a critically needed change that will cut into some of the problems we're having. I'd like to see legislation that would require it.