As the U.S. opioid addiction crisis continues to worsen, the pharmacy industry’s role in addressing the epidemic continues to increase. Around 68% of more than 70,200 drug overdose deaths in 2017 involved an opioid.1 Moreover, about 80% of people who use heroin first misused prescription opioids.2 Since the next patient standing across the counter could easily be an at-risk patient, or even a potential perpetrator of fraud or abuse, are pharmacies doing everything possible to vet each patient interaction?
The Power of Observation
There are obvious situational markers that pharmacists flag and follow-up on, including cash-only buyers, late-night fills, and group approaches. Experienced pharmacists are dialed in to the physical and behavioral qualities surrounding a member’s fill of controlled substances. Provider information; authenticity of the script; and the proximity between provider, patient, and store are all things that can prompt a pharmacist to ask follow-up questions.
Technologies exist that allow pharmacists to confirm prescriber’s eligibility, patient identity, as well as to query a state prescription drug monitoring program (PDMP) database; however, they are not interconnected or not sufficiently integrated in pharmacists’ workflows. Working in disparate systems, pharmacists can spend several minutes manually clicking through multistep processes and systems when verifying a single controlled substance prescription.
Pharmacies have begun to implement policies and technologies to help reduce or eliminate opioid fraud at their locations. Whether limiting opioid prescriptions to a seven-day supply for certain conditions or consulting with patients for opioid prescriptions regarding addiction risks and safe storage and disposal, pharmacies are taking a more proactive role in addressing the obstacles.
Today’s technology: mining big data for meaningful data
Despite these steps in the right direction, there is much more that the industry can do to accurately safeguard patients who are at-risk and promptly identify potentially risk-taking fraudsters.
The primary avenue for opioid abuse is drug diversion — one individual transferring prescriptions to another for use or resale. Because drug diversion is a social phenomenon, with little to no indication found in medical data, adding public records data to transactional prescription datacan deliver potential diversion indicatorsthat no data set can surface on its own. Such technology can identify connections among individuals and their interactions with providers, pharmacies, or even other patients, flag aberrant behavior patterns, and thus help pharmacists accurately determine who may be at risk for potential fraud or abuse.
Data and analytics tools can detect provider prescriptions for excessive quantities, prescriptions to family members or large social groups, or prescriptions that do not correspond with a medical event and flag them as “risks.” For instance, looking at a sample customer data set, LexisNexis identified 3,080 scripts, or 0.01%, that were written for a relative or an associate of the prescriber.
Likewise, technology can correctly flag individuals who are potentially at risk for overdose, abuse, or diversion. Some patients “doctor shop” and get many prescriptions filled by various providers in a relatively short amount of time in order to subvert current process communication windows. This is why analysis of patients’ daily morphine equivalent dose (MED) can be revealing. In another instance of sample data analysis, LexisNexis identified several individuals with daily MEDs above 120 milligrams across all drugs, including an individual with 187 milligrams. In all analyses, it is vital to ensure patient identity is correctly resolved, (i.e., establishing whether slightly modified names such as “Jon Smith”, “John Smith” or “Jonathan M. Smith” are one or different individuals).
Working Towards Industry Collaboration
While a pharmacy can benefit from insights about what is happening in its stores, in many cases it misses the big picture view of what substances the patient has received from other pharmacies, if the patient demonstrates other potential signs of addiction, if the patient’s connections are also visiting the same prescriber, and whether they’ve all attempted to obtain the same script. For the safety of patients and betterment of the industry, a contributory prescription database for information-sharing is the ultimate goal and would bring immense value in addressing this epidemic.
Craig Ford is Vice President for pharmacy and Rick Grape is director of market planning at LexisNexis RIsk Solutions Health Care